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MEDICAL RECORD.

A JVeekly yoiirnal of Medicine and Surgery

EDITED BY

THOMAS L. STEDMAN, A.M., M.D.

IrJolumc Q>Q>.

JULY 2, 1904— DECEMBER 31, 1904

NEW YORK
WILLIAM WOOD AND COMPANY

1904

Medical Record

A Weekly Journal of Medicine and Surgery

Vol. 66, No. I.
Whole No. 1756.

New York, July 2, 1904.

$5.00 Per Annum.
Single Copies, lOc.

CPrtginal Arttrba.

THE DISTIN"CTIVE CHARACTER OF THE
TEMPERATURE CURVE OF MEASLES AND
OF SCARLET FEVER; AXD THE TREAT-
MENT OF HYPERPYREXIA IN THESE
DISEASES BY BATHS OF INCREASING
TEMPERATURE.*

Bv HENRY W. BERG. M.D..

NEW YORK.
VISITING PHYSICl.^N TO THE WILL.\RD PARKER AND RIVERSIDE HOSPITALS;
ADJUNCT PHYSICIAN TO MOUNT SINAI HOSPITAL; INSTRUCTOR IN IN-
FECTIOUS DISEASES. COLUMBIA UNIVERSITY.

The clinical observation of measles and scarlet
fever in hospital and private practice has led me to
the conclusion that the temperature curve in these
two acute infectious diseases is as characteristic
and distinctive for each of them as are the respective
curves of typhoid, typhus, and smallpox. I am
well aware that this is not the view of the vast
majority of writers on measles and scarlet fever,
and it becomes all the more important that each
of us who sees much of these diseases in a system-
atic way should add his quota of observation to
the recognition of the normal course of the tem-
perature curve in these extremely common affec-
tions.

The' temperature curve of the acute infectious
diseases is divisible into three stages: (i) That of
accession, including the beginning and rise of the
temperature to its maximum; (2) the fastigium
or stage during which the temperature continues
at its height before the positive decline has set in,
which forms (3) the stage of defervescence. The
first stage may be an acute steep rise to a high
temperature in the course of a few hours, or a
gradual rise, continuing for days before the fas-
tigium or period of maintenance is attained. The
second stage, or fastigium, also varies in duration
in different diseases. In some the temperature is
maintained for some days, in others the fastigium
is scarcely attained before the third stage of the
temperature, or that of defervescence, begins. Of
the third stage, there are two types. When -t
declines rapidly, as in pneumonia, the temperature
is said to resolve by crisis; when it declines gradu-
ally by a slow diurnal descending staircase move-
ment, the resolution is by lysis.

Before discussing the temperature curve of the
two diseases to which these observations are limited,
I wish to object to the customary description of
the symptoms of measles and scarlet fever under
the head of the stage of invasion or prodromal stage,
the stage of eruption, and the stage of desquamation.
The stage of invasion or prodromal stage corres-
ponds with the appearance of the enanthematic
eruption upon the mucous membranes, those of the
conjunctiva, the nasal fossae, buccal cavity and inside
of the lips and cheeks in measles, and the pharynx,
tonsils, and tongue in scarlet fever. This stage is
as much a part of the eruptive stage as is the ex-
anthema itself. The so-called prodromal tempera-

*Read before the New York Academy of Medicine, May
19. i9°4-

ture is the temperature of the enanthematic stage
of the eruption-. The conception of the desquama-
tive stage as synonymous with that of defervescence
is also faulty, in that it would give the impression
that desquamation begins with defervescence or
disappearance of the eruption, which is rareh' true
even in measles, and is never true in scarlet fever.
Every one who sees much of the latter disease
knows that, as far as the skin lesion of this disease
is concerned, there is in a large proportion of cases
a period of three to eight days or more after the
eruption has entirely disappeared and the skin has
become normal to the eye and touch before des-
quamation begins. During this period the most
expert clinician could not, in many cases, affirm
from the presence of any positive symptoms that
the patient had suffered from scarlet fever, and
when the history points to that disease he awaits
the appearance of the characteristic desquamation.
While this is not true of measles, in which the skin
does not return to its normal color or appearance
until after desquamation is completed, yet even
here the fading of the characteristic erupt'on is not,
as a rule, immediately followed by desquamation,
but there is generally a period of some days before
desquamation sets in. If these diseases must be
described clinically under the head of stages, it
would be more logical and true to write of them as
(i) the eruptive stage, including the enanthematic
and exan thematic periods; (2) the stage of defer-
vescence; (3) the stage of desquamation.

The pyrexia of measles and scarlet fever, due to
the respective specific infectious cause of these dis-
eases occurs during the eruptive stage as thus de-
fined and the stage of defervescence. By that I
do not mean that the rise and fall of temperature
that occurs during these stages of all cases of measles
and scarlet fever is due to the specific virus of
these diseases, emphatically not; for very many
suffer during the earliest as well as the latest
stage from a variety of complications and mixed
infections, each of which causes modifications and
deviations from the temperature curves character-
istic of measles and scarlet fever when these diseases
are uncomplicated. What is meant is that the
characteristic temperature curve of measles as well
as the characteristic temperature curve of scarlet
fever covers the stage of eruption and the stage of
defervescence.

Let me then describe the characteristic tempera-
ture curve of an uncomplicated case of measles in
which there is pyrexia. During the enanthematic
period of the eruptive stage the pyrexia is moderate ;
it rises toward night, it declines about a degree
toward morning. It lasts for from two to five davs.
There is a slight increment of pj^rexia every even-
ing as compared with that of the evening before.
There is, however, a sharp decline, sometimes to
within a degree of the normal, on the morning of
the day when the skin eruption (face) is to appear.
Synchronous with the appearance of the exanthema,
the pyrexia becomes greater and the temperature
rises rapidly, generally to a higher point than any

MEDICAL RECORD.

[July 2, 1904

reached during the enanthematic period of the one or two degrees by morning of the next day.

eruptive stage. On the first day of the skin erup- During this day the eruption becomes complete,

tion, with the appearance of the exanthema on the covering the legs and dorsum of the feet. The

face, the temperature is apt to be a degree higher temperature again rises toward night, but not as
than the highest figure of the enanthematic stage.
From this figure there is a decline of about a degree

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Schematic Measles; 1. enanthema; j, e.xanthema.

by the following morning. During this second
day the eruption covers the neck, chest, arms,
and shoulders, and toward night the pyrexia is
about a degree higher than that of the evening
before; there is a slight decline toward next mom-

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Chart a. Measles, Jos. E, : i, enanthema; 2. exanthema.

ing. On that day the eruption covers the ab-
domen, back, and thighs, and the temperature rises
by evening a degree or a degree and a half higher
than the evening preceding. This is the ma.ximum
height during the whole course of the essential
temperature curve of the disease. It again falls

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Chart 3. Measles. Defervescence. Oukio R.

high as the night before. During the night and
following morning there is a decline or defer\'escence,
abrupt and sharji, either down to the normal or

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Chart 4. Measles, Defervescence. Jos. F.

almost normal, within twelve to twenty-four hours,
or the abrupt decline may be interrupted at about
midway by a slight evening rise and then an abrupt

July 2, 1904]

MEDICAL RECORD.

decline to the normal by the following morning.
This is schematically shown in chart i and in chart
2. the latter a complete uncomplicated measles
curve from a case in private practice. If I were
asked to indicate the most characteristic phe-

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Chart 5. Measles, .\niue G.

nomenon in the typical measles tempera ture curve-
I shoiild say that it is this tendencj' to resolution
or defervescence of the pyrexia by crisis. In this
respect it differs positively and absolutely from
the temperature curve of scar-
let fever, in which, as I shall
presently show, the resolution
of the pyrexia takes place by
lysis. I J I'

Frequently in severe Teases
of uncomplicated measles the
writer has been able to predict
that the temperature would
fall to the normal on a certain
given day, although on the
day previous, at the time of
the statement, the tempera-
ture was still at a very high
and even alarming figure. This
prognosis rested upon the
absence of any complication
in that particular case, and my
absolute reliance on the posi-
tive fact that the pyrexia of
uncomplicated measles always
undergoes a resolution by crisis,
as indicated above. The tem-
perature curves taken from the
histories of normal uncompli-
cated measles cases demon-
strate graphically what I have
attempted to describe at length.

(Charts 2, 3, 4, 5, and 10.) AH but chart 2 are
temperature curves from cases in the Riverside
Hospital.

Scarlet fever, when uncomplicated, has a much
simpler temperature curve than measles. Never-

theless this curve is characteristic of this disease
During the development of the enanthema syn-
chronous with the initial vomiting and sore throat
the temperature reaches a ver\' high degree, fre-
quently the highest point of the temperature curve.
The enanthematic eruption is ver\- rapidly followed
by the exanthema, sometimes within six or eight
hours, generally within one or at most two daj's.
During this time the temperature is maintained
at its height, suffering only the usual decline of a
degree or a degree and a half toward morning, to
rise again at night. If the skin eruption is delayed
a slight drop in temperature precedes it. (Chart 7,
from a case in private practice.) With the appear-
ance of the exanthema the temperature is main-
tained at its height for three or four days more,
while the eruption covers the body. The first
slight decline is noticed when the eruption has
reached the lower part of the legs and dorsum of
feet, about the third or fourth day. This decline is
slight, not more than two degrees, followed by a
slight rise at night, but not as high as the tempera-
ture of the previous night, next morning again to
decline to a degree or a degree and a half lower than
the morning before, and so on, the teniperature
curve descending by steps ver\- much after the man-
ner of the typhoid curve until the normal is reached
after five to eight days. In this disease the def-
ervescence of the pyrexia is by lysis. This cur^'e
is schematically shown in chart 6, while chart 7
shows a curve from a case of uncomplicated scarlet
fever observed from its very beginning to its end.
The temperature curve of measles as compared
with that of scarlet fever shows the following points
of difference: In measles the accession of the fever
is gradual (shown in charts e, 8, and 9), the fas-
tigium limited (charts i and 2), and the defer-
vescence by crisis (charts i, 2, 3, 4, and 5). In
scarlet fever the accession is acute (charts 6 and 7)
and sudden, the fastigium lasts through almost the
whole of the eruptive stage (charts 6 and 7), and
the defervescence is by lysis (charts 6, 7, 11, 12,

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Chart 6. Schematic Scarlet Fever; 1. enanthema; 2, e.xanthema.

13, 14, 15, and 16).* I have spoken only of the un-
complicated measles and scarlet fever temperature
curve, carefully abstaining from giving any abso-

(*Charts 10 to 16 are from cases in the Riverside Hos-
pital, scarlet-fever service.)

.MEDICAL RECORD.

[July

1904

lute temperature figures. For the general trend
of a temperature curve that is distinctive and
characteristic of a disease must be true, whether
the p3-rexia be a severe one with high temperature,
or mild with very low temperature.

There are said to be also cases of measles and

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Scarlet Fever; i, enanthema; 2, exanthema

scarlet fever which run their course without any
temperature. I have never seen such a case in hos-
pital or private practice. I have frequently seen
cases in which the fever has been verj- slight, but
recognizable by rectal thermometric ob.servations.
I have certainly heard from mothers whose children
showed b}' a characteristic desquamation and other
sj^mptoms that scarlatina had run its course in the
little patient, and that there had been no fever
accompanying the rash, but s\jch statements resting
solely upon nonprofessional observation and fre-
quently lack of observation can hardly be taken
as the basis for clinical data.

Of great importance is the fact that eminent au-
thorities differ as to whether the temperature
curves of measles and of scarlet fever are respectively
distinctive of these diseases. Scarcely any two
works on medicine agree as to the temperature
curves of either measles or scarlet fever. Thus
Wunderlich (Eigenwarme in Krankheiten, 1870),
whose thermometric studies are classical, considers
the measles curve absolutely distinctive, and that
of scarlet fever also, under certain limitations. The
curve for scarlet fever, which I have found in mv
experience differs from that of Wunderlich in many
particulars, and my impression does not confirm
the views of Wunderlich with regard to the measles
curve in many rcsiJects, but the critical deferves-
cence in measles and the defervescence by Ivsis in
scarlet fever Wunderlich emphatically recognizes.
Indeed, this shrewd obser^'cr makes this broad
statement:

"The course of the temperature must be individual
and characteristic in each separate infectious dis-
ease ; each must present its typical curve, and if we
fail to recognize it, the fault certainly lies with us."
(Uber einige Verhaltnisse des Fieberverlaufes bei
Masem, Archiv der Hcilkmide, 1863, p. 332.)

Just as we commonly accept as characteristic of
smallpox, its well-known, peculiar temperature
curve, and as characteristic of typhoid and typhus
fever, the recognized curve of the pyrexia in these

diseases respectively; to this extent at least, is the
fever curve in measles and scarlet fever distinctive.
The objectors to this view, prominent among whom
are Thomas and also von Jiirgensen, seem to expect
more uniformity in the course of the fever of
measles and scarlet fever as a sine qua noti, for con-
sidering them distinctive, than
they do from the curve of the
fever in typhoid and typhus,
which they agree are eminently
distinctive. And yet variations
from the typical fever course in
measles and scarlet fever can be
accounted for more easily and
are far less numerous than the
variations from the typical
course in typhus and typhoid.
One important reason why phy-
sicians do not recognize how
typical are the fever curves of
measles and scarlet fever, lies
in the fact that pyrexia in these
diseases, when uncomplicated, is
much shorter in duration than
that of typhoid and typhus.
Then, too, complications of an
inflammatory nature frequently
mask the characteristic curve in
scarlet fever and measles. Es-
pecially is this true at the period
of defervescence, when, in an un-
complicated case, the fever would
def ervesce by crisis or pseudocrisis
in measles, and by lysis in scarlet
fever. Then, too, measles and scarlet fever can be
observed in numbers sufficient to enable one to
make deductions as to the fever curve only in infec-
tious disease hospitals which are few in number;

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Measles, end of enanthema and beginning of exanthema.
Louis L.

while of typhoid every general hospital furnishes
sufficient material. Even in infectious-disease hos-
pitals the cases come in too late for frequent obser-
vation of the first two, or even three, days of the
curve. I have been compelled to study the behavior

July 2, 1904]

MEDICAL RECORD.

of the fever curve in the first days of the disease,
in ni)- private practice.

I present some curves of the earlier days of two
measles cases which I owe to the courtesy of Dr.
M. Gershel. Physician to the Hebrew Sheltering
Guardian Society (charts 8 and 9).

I have sought to explain the fever curve of
measles and of scarlet fever. In both of these dis-

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On a similar basis can be explained the rise in
temperature with the appearance of the eruption on
the face; the further rise on the following day as
the eruption covers the chest; the rise to the
maximum of the curve as the eruption spreads over
the largest area on the third day of the exanthema,
when the eruption covers the abdomen, trunk, and
thighs; the decline as these surfaces are covered,
f'^llowed by a rise, to a lower plane, however, with
the appearance of the rash on the lower legs and
dorsum of the feet, owing to the fact that the
cxtaneous surface involved is far less in extent than
that covered on the day previous; and, finally, the
rapid decline by crisis to the normal, due to the fact
that the inflammatory disturbance in the cutaneous
surface has run its course. All of these changes can
be explained by taking these two causative factors
of the pyrexia into consideration.

Nor is it essent'al to believe that with the disap-
pearance of the fever, the toxic element should have
been entirely extruded, provided a sufficiently large
share of it has been neutralized and excreted by
the skin and mucous membranes, so that it is no
longer necessary for the body cells to continue the
excess of chemical and biological activities of which
the pyrexia was a manifestation and which pre-
served the cells in their contest against the
activities and products of the hacteria of which
the infection consists. _

In scarlet fever the toxic agent plays a more im-
portant role in the production of the pyrexia than
does the inflammation of the skin or mucous mem-
branes; nevertheless, the latter, as in measles, has
its effect, as is well shown in cases of scarlet fever
in which the enanthema is not followed within a few
hours by the exanthema on the shoulders and face

Ch.\rt 9. Measles, showing cun.*e of exanthematic stage.
Clara C.

eases the pyrexia is the combined result of the in-
fluence of the pathogenic germ and its toxins upon
the various biological and chemical processes going
on in the blood and tissues of the body, which are
heat producing, as one factor, together with the rise
in temperature produced by the inflammatory
process going on in the mucous membranes and
skin, to which the enanthema and exanthema are
due, as another factor. I believe the latter factor to
be dependent upon the former, for, in my opinion,
the eruption in the acute exanthemata is simply a
conservative inflammatory manifestation on the
skin and mucous membranes due to their activity in
helping to excrete from the system the toxic mate-
rials present in the blood and tissues. The influence
of the toxaemic element in the production of the
pyrexia is less in measles than it is in scarlet fever.
On the other hand, the cutaneous inflammatory
process involved in the eruption of measles has a
more important influence on the pyrexia curve than
the skin lesion of scarlet fever has on the tempera-
ture curve of that disease.

Keeping these two causative factors of the pyrexia
i n viow, let us consider in the light of them the measles
curve. The first portion of the pj'rexia curve, dur-
ing the enanthema is moderate even in cases of some
severity, about 103° F., and is due to the catarrhal
inflammation of the mucous membranes of the
•mouth, nose and eyes, plus the effect of the activities
of the toxic agents. The slight drop in the fever
before the appearance of the exanthema is due to
the fact that the acme of the inflammation in these
mucous membranes has been passed and that causa-
tive element in the pyrexia is therefore diminished.

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Ch.^rt io. Measles, Defervescence. John H,

as is usual, but where such exanthema is delayed
for two or more days, as is the case in the curve of
normal scarlet fever shown in chart 7. In such cases
there is a drop in the high temperature after the
enanthema has appeared and before the exanthema
appears (charts 6 and 7). But when the eruption
becomes manifest the temperature rises to the high

MEDICAL RECORD.

[July

1904

point which it had attained with the initial tonsillitis
and pharyngitis and vomiting, and the fastigium
lasts, as already shown, with a slight increase on the
third day of the eruption, for reasons similar to those
spoken of under measles, but otherwise not showing
the daily increment in the fever due to the involve-
ment of additional skin areas in the eruption. For,
in this disease, as I have already said, the local skin

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Chart 11. Scarlet Fever. Defervescence.

John McK.

lesion plays a much less important part in the pro-
duction of the pyrexia than does the toxtemia. The
whole clinical picture of scarlet fever supports this
view; the initial toxic vomiting, the rapid pulse and
the frequency of toxic complications. This toxic
element is sufficient to keep up in the body cells
their fever-producing activities
even after the eruption has
reached its height and is sub-
siding. However, gradually the
toxic agents are overcome, and
this slowness is pictured in the
gradual resolution of the fever
by lysis ; the temperature , while
declining daily, does not reach
the normal until four days
to a week or more after the
eruption has run its course.
(Charts 6 and 7, and other
defervescent scarlet fever tem-
perature curves.)

With this view of the tem-
perature curve and its patho-
genesis, it is possible bj' carcfvil
examinations of the patient
from day to day to account for
any positive departure from
the typical fever curve in
those suffering from these two
diseases. Nor is it surprising
that slight variations occur
even when there are not de-
cided complications. These

two eruptive fevers, for the most part, affect
children in whom even the normal tempera-
ture curve of the body in health is readily dis-
turbed by comparatively unimportant factors,
and yet so tj'pical are the respective fever curves
in these two diseases that variations in uncom-

ful study of each case,' and will serve only to
prove the rule. Such reliance can one place upon
the typical character of the curve, in my experience,
that if a positive variation from the usual cur^'e is
seen, a complication must be sought for and will
generally be found. Thus, if the critical drop in the
temperature curve of a measles case in the defer-
vescence of the fever has taken place, and a rise in
temperature follows, it can be
positively affirmed that there
is a complication, such as pneu-
monia, otitis media, meningitis,
etc., which a careful ex-
amination of the patient will
reveal. If the critical resolu-
tion does not occur, but defer-
vescence is only partial, the
fever continuing as the eruption
is fading, a complication, as a
cause for the continued fever,
will be found. Furthermore, if
the course of the fever is not in
a general way in accordance
with the typical curve through-
out the whole of the eruptive
stage, and a careful examination
reveals no complication, I have
generally found that the criti-
cal defervescence will not oc-
cur, and gradually the con-
cealed complication shows itself.
In other words, an irregular
curve will put the careful clin-
ician upon his metal to dis-
cover the complication which
causes the irregularity. In one of my cases an
inflammatory rheumatism, involving at first only
the vertebral articulations but later on other joints,
gave rise to a septic temperature curve in a case of
measles with a typical enanthematic and exanthe-
matic eruption. Even the presence of very high

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plicated cases will admit of explanation on care-

pj'rexia in cases with a normal measles temper-
ature cur\^e enables him who is familiar with the
measles curve to predict a critical drop at the proper
time, especially if a careful physical examination has
failed to reveal any complicating condition.

In scarlet fever a knowledge of the normal curve
will enable the physician and the patient's friends

July 2, 1904]

MEDICAL RECORD.

to look with equanimity upon rather high tem-
peratures during the fastigium, provided no com-
plications are found. When, however, in the stage
of defervescence resolution by lysis has begun, and
after a day or two is interrupted by a renewed rise
to the higher figures of the fastigium. then a com-
plication must be sought for and found, for the

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Chart 13. Scarlet Fever. Arthur M.

scarlatinal virus uncomplicated never causes a
renewed rise of temperature in the stage of defer-
vescence when lysis is in progress.

A knowledge of the normal temperature curve of
scarlet fever will enable us to estimate at its true
value any serum therapy proposed as a specific for
the disease. For a specific serum treatment tried
even in large numbers of cases
may result, owing to the severity
of the cases upon which it has
been tried, in a larger death
rate than that shown in the
total mortuarj' statistics of a
city where the death rate is
based on all the cases of scarlet
fever which have been reported,
both severe and mild. But if
the serum recommended really
antagonizes the toxic elements
of the disease, it must necessarily
cut short the fever which is also
dependent upon these toxic
agencies. I should expect
such specific serum injections,
whether of the antitoxic or
antibacterial type, to produce
a prompt shortening in the
duration of the fever of the
fastigium and a defervescence,
of the critical type, within
twelve to twenty-four hours
after the injection. I have
accordingly attached no im-
portance to the antistreptococ-

cus serum therapy, owing to the fact that in the
cases in which I have observed the Marmorek
and Moser serum used, I have failed to see such
or like influences upon the typical temperature
curve of scarlet fever, as a sequence of these serum
injections. A recovery after the use of the serum
means little, for scarlet fever is cured without serum
therapy. A change in the curve of the deferves-

cence from lysis to crisis would mean very much.
The successful antiserum, when discovered, I am
sure, will show as one of the important clinical
changes, a shortening of the fastigium of the fever
curve and a resolution of the fever by critical drop
and not by lysis.

In the course of my remarks I have purposely
avoided any reference to abso-
lute high or low temperatures in
measles and scarlet fever, the
object of this stud}' being the
development and recognition of
the typical character of the un-
complicated temperature curve
from day to day, irrespective
of its absolute height or low-
ness. I may be permitted,
however, to speak of the prac-
tical and important question of
the treatment of hyperpyrexia
in these two diseases. I think
we may assume, for the purposes
of this paper, that occasionally
in measles and scarlet fever
even when uncomplicated, the
temperature, owing to its extra-
ordinary height, may require
therapeutic attention. This, not-
withstanding the fact that from
what has been said, our knowl-
edge of the character of the
curve enables us to predict its
duration and probable extent
as long as no complicating con-
ditions occur. All the more does the temperature,
when excessive, require attention in those cases
in which complications exist; for not only is
the temperature in some of these cases apt to
rise to much higher levels, but owing to the
uncertainty of its duration we must avoid as far as
possible the evil effects of hyperpyrexia which the

-11

16v 1 li

AMPM

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AMPM

AWf

AMPM

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loX

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: \

•

\o{i

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'li*

V ■

Chart 14. Scarlet Fever, Defer\-escence. Rose G.

patient may have to endure for some time. The
usual methods for reducing temperature in infectious
eruptive fevers, employed also in measles and
scarlet fever, are cold or cool baths, like the Brand
baths, used in typhoid, cold or cool sponge baths,
cold pack, and antipyretic drugs. The last, we may
dismiss with an interdiction. I do not know of any
of the acute infectious diseases in which these drugs

MEDICAL RECORD.

[July

1904

are warranted for the reduction of hyperpyrexia.
The reasons for this are for the most part well kno-wTi
and we need not enter upon them here. As far as
the use of the other three methods is concerned,
baths, sponge baths, and the cold pack, one fact is
true with reference to all three of these methods of
reducing hyperpyrexia when applied to measles and
scarlet fever, and that is that
no such reduction of tempera-
ture, either in amplitude or in
duration, as is obtained from
these methods in the high tem-
peratures of other diseases, such j^j
as typhoid or pneumonia,
takes place from their use in
the pyrexia of measles and
scarlet fever. This is easih^
accounted for. In both of
these eruptive diseases, cold,
-whether in the shape of baths,
^sponging or packs, has a
■different effect upon the skin,
which is the seat of an ex-
anthema, from that which it
has in diseases in which the
skin is in a normal conditir)n.
The subcutaneous swelling and
infiltration which is a part of
the eruption causes pressure
upon the cutaneous capillaries
and their nerves. These capil-
laries do not undergo the
primary contraction under the
influence of cold which occurs
when cold is applied to healthy
secondary dilatation which follows the primary in-
stantaneous contraction where the skin is normal,
occur in skiii which is the seat of a measles or scarla-
tinal eruption. There is, therefore, not that inter-
change of cooled blood from the periphery and
warm blood from the center which is so necessar\^
a condition to the reduction of temperature by cold

primarily and secondarily. I have referred above
to the importance of the sweat glands in aiding the
skin to excrete from the body the toxic materials
which are the essence of the disease in measles and
scarlet fever. I even believe that the eruption itself
is the conser\-ative manifestation of the eliminative
activity on the port of the skin; so that any method

4 : 5 : 6

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ftMPM

AMPM

AMPM AMPM

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^n'^

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skin,

Chart 15
nor does the

Scarlet Fever. Defervescence. Sylvester M.

n n

AMPM

WPM

AMPM

1MPM

AMfM

AMHM

4MHM

AMHM

105'
103'

lor

100-

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Chart i6. Scarlet Fever. Defervescence. Elsie K.

baths or pack. On the contrary, I have seen these
agents when applied to a brilliant scarlatina cause
the red rash to become violet and almost hemor-
rhagic and spotted in character, owing to stasis of
the cutaneous circulation.

For the same reason cold baths and cold packs in
measles and scarlet fever inhibit perspiration both

of reducing temperature which inhibits the elimina-
tive and excreton' functions of the skin defeats the
most logical indication for therapy that we have in
the acute infectious eruptive diseases. A gentle
perspiration during the course of the eruptive stage
of measlesand scarlet fever is desirable, and all ther-
apy should be directed toward its encouragement.
Whenever a case of measles or scarlet fever with high
temperature and other toxic phe-
nomena shows but a scant and
incomplete eruption. I practice
and advise the giving of a warm
bath followed by a dry pack.
The perspiration which ensues
is generally successful in bringing
out the eruption, while at the
same time the temperature will
sink materially and the curve be
completed on a lower plane.

This is onl)!- done if with hyper-
pvrexia the eruption is incomplete.
To reduce abnormally high tem-
peratures (above 104°) in uncom-
plicated or complicated measles or
scarlet fever, I have used for some
years the following method : The
patient is placed in a bath with
the water at a temperature of
So'F. ; at the end of five or ten
minutes, depending upon the case,
the temperature of the water is
raised to 90" by the addition of
warm water. A bath at 80' for
a fever patient with temperature

of 105° is a cooling bath, and yet not cool enough
to produce the evil effects upon the capillaries of the
skin of which I spoke above. The subsequent raisivg
of the temperature of the water ten degrees for ten
minutes is equivalent to giving a warm bath after the
cool one to the patient who has become accustomed to
the water at 80', Whatever ill effect the cool bath

July 2, 1904]

MEDICAL RECORD.

at 80" imay have had upon the cutaneous capillaries
and nerves is more than counterbalanced, and yet
the temperature of the bath is still at 90' — much
lower than that of the skin. The patient, when
taken from the bath, is wrapped lightly in a sheet
and covered lightly by a thin blanket. The tem-
perature will be found to have declined from one and
one-half to three or more degrees, and the decline
persists longer than from any other method that I
have tried in these diseases. Moreover, the eruption
is not diminished, the pulse is improved, sleep
generally induced, and a gentle perspiration covers
the whole body. Practically, one point of impor-
tance must not be forgotten. When the warm water
is added it must be poured into the bottom of the
bath tub. The reason for this is that if the warm
water is poured on the top, it floats over the cool
water, unless imperfectly mingled mechanically by
the nurse. The patient would thus have the lower
part of his body bathed in cold water and the upper
part in warm or hot water. For this purpose I have
used in private houses a tin funnel with a piece of
rubber hose long enough to reach to the bottom of
the tub, and thus the warm water is delivered at the
bottom of the bath. It then rises by its own light-
ness, as compared with the cold water, and is dis-
seminated throughout the bath. For hospi.tals, a
tub with a false fenestrated bottom can be made,
and a permanent tin tube passed along one of the
sides to the bottom, to accomplish more easily the
same purpose. The patient should not be rubbed
after such a bath, both because the warm additional
water accomplishes all or more than the rubbing in
the Brand bath, and for the further reason that
friction is detrimental to the inflamed skin,
producing a pseudo-desquamation long before the
subjacent skin is ready to cast off its inflamed
covering. Such desquamated areas of skin are
practically superficial ulcers.

Lesser degrees ®f hyperpyrexia are treated by
sponging with water at 70*, to which one -third
ordinary alcohol has been added. The alcohol in
these cases acts the part of the added warm water
in the bath, and counteracts the ill effects of the
cold sponging upon the capillaries and nerves of the
skin. It is unnecessary to again repeat the in-
junction against the use of friction upon the skin.
On the contrary, the sponging should be liberally
done with a large soft sponge, only the excess of
water absorbed by patting the skin with a soft towel
and the patient lightly covered as after a bath.
Of these two methods the most efficacious in very
high temperatures of scarlet fever and measles has
been the tub bath as above described.

With a knowledge of what is the normal and
expected course of the temperature in uncomplicated
cases of these diseases, we should be able from
carefully kept charts to receive mxxch aid in the
differential diagnosis of these affections when they
resemble each other, in the early recognition of com-
plications and in the prognosis of individual cases.
We should be able to estimate at their true value
specific sera that may be recommended for the
treatment of measles and of scarlet fever by their
effect upon the normal temperature curve. The
efficacy of the methods I have described for the
treatment of hyperpyrexia in these conditions will
be my excuse for a conscious offense against unity,
in thus discussing or combining in one paper two
closely allied, but yet separate and distinct topics.

The charts from the cases in the Riverside
Hospital were furnished me by Dr. Watson, acting
resident physician, and Dr. Horwitz, interne, at the
Riverside Hospital, to both of whom I hereby ex-
press my sincere thanks.

921 Madison Avenue

GRAVE AN/EMIA DUE TO HOOK-WORM IN-
FECTION.*

By LOUIS M. WARFIELD, A.B., M.D..

SAVA.VN.\H. GA.
FORMERLY HOUSE MEDICAL OFFICER OF THE JOHN'S HOPKINS HOSPITAL.

The recognition of the true etiology of a group of
anaemias prevalent in our Southern States is of
comparatively recent date, and the role played by
the intestinal worm. V ucinaria americana (Stiles)
is as yet little appreciated. The succession of
events from 1901, when Stiles made the suggestion
that we probably had in our midst a worm similar
to, if not identical with, that found in Egypt, Eu-
rope, and the Tropics, which caused the so-called
"brick-makers' anaemia," "miners' cachexia," etc.,
to the present status of Uncinariasis, has been both
rapid and startling. W'ho would have supposed
that within two short years all our ideas of one
group of anaemias, in the South especially, would
be so upset? From time immemorial malaria and
the miasm of swamps have served as diagnostic
rubbish heaps, where practically all cases of anaemias
were indiscriminately thrown. Now, however,-
thanks to the labors of Stiles, Ashford, Harris, and
others, we are waking up to the fact that we have
a disease easy to diagnose and easy to cure that is
responsible to a great extent for the lifelessness and
unproductiveness of the country commimities.
Strange it is that a disease so easily recognized
should so long have waited to be accurately diag-
nosed. It represents a triumph for science and
microscopical methods in the hands of earnest
seekers after truth.

The cases reported are few. Case 5 in particular is
the only one of its kind that I have seen or heard
of. The interest lies in the fact that it suggests
possibilities of mistakes in diagnosis, and for this
reason more than any other I present the case. First,
let me relate briefly the histories of four other
cases:

Case I. — Wm. C, age twenty, white, comes from
Higgston, Ga., admitted to the Savannah Hos-
pital, August 18. 1903. complaining of sores on
penis. He says all his family are tall, well-built
people. The patient up to ten years of age was well,
except for chicken-pox. At age of ten he had rheuma-
tism, which confined him to bed for nearly three
years and left him a cripple. He has had ground-
itch five times, the last attack three years ago.
He lives among the pinej^ woods on sandy soil, and
says that many sallow people are in the town.
Three months ago he contracted a venereal sore,
which was diagnosed as chancroid. He has lost
in the past year some weight and much strength.
For our purpose his present illness began about
ten months before admission. He began "to go
down hill." felt drowsy all the time, and had a dis-
disinclination to move around. Does not think
his disposition has changed. No loss of appetite,
no diarrhoea at any time, and he never noticed
that his stools at any time contained blood. Has
suffered with shortness of breath and palpitation of
the heart. Physical examination shows the pa-
tient to be undersized, underdeveloped, and dull
intellectually, about 5 feet 3 inches in height. Small
dressing on bridge of nose where abscess was
opened. W'alks on crutches. Complexion sallow,
mucous membranes pale; very few vessels can be
seen in conjunctivae. Sclerotics of normal white-
ness, pupils slightly dilated, equal, react normally.
Soft systolic murmur at second left interspace.
Heart not enlarged. Pulse regular in force"~and
rhythm, good volume, rather low tension, 20 to \.
Abdomen flat, no tenderness. Spleen felt extend-

*Read before the Georgia Medical Society.

MEDICAL RECORD.

[July 2, 1904

ing 6 cm. below costal margin. Liver not en-
larged. Healing sores on penis. Testicles small,
no nodules. Legs show typical picture of arthritis
deformans. The patient was seen by me on Sep-
tember 16. A specimen of stool showed numerous
ova of uncinaria in all stages of segmentation.
The stool had a peculiar granular appearance,
dark brownish-red in color, with a curious odor
which was not disagreeably fecal, combined with
an odor somewhat resembling stale blood. A piece
put on a sheet of white paper and allowed to stand
for an hour left a reddish-brown stain, which is said
to be of diagnostic value.

September 18. — Thymol was given in divided
doses, followed by castor oil. All stools were lost.
Since admission the patient has had an irregular
temperature, reaching almost every afternoon to
99° or loo" F., returning in the morning hours
nearly to, or quite to, normal.

September 19. — Temperature subnormal, and
up to the time of discharge on September 26, it
was never 99° F. The patient was given two
other courses of thymol, but through some mis-
understanding all the stools were lost.

September 25. — Discharged at his own request.
He is much improved, but a few eggs are still to be
found in the stools.

C.\SB II. — Wm. S., age eighteen years, Screven,
Co., Ga., complains of shortness of breath and
feeling badly. This patient was under the care
of Dr. Carter, at whose suggestion I examined the
stools. The patient says his family are well. All
are full-sized. His father used to be sickly, but
now seems quite well. He himself has always
been sickly. Used to feel tired and drowsy, and
was subject to attacks of diarrhoea. He has had
repeated attacks of grounditch, the last attack
two years ago. For some time he has been a mes-
senger boy. His health at present is much better
than it ever has been. The patient was seen by
me on September 14. He had been under Dr.
Carter's care for several months, and had improved
considerably under treatment with iron and tonics.
He had had a dilated heart and all the symptoms
of grave anaemia. He had constantly a low fever
from 99° to 100" F. Status prassens: A markedly
sallow, underdeveloped boy, cheeks puffy and skin
tough, parchment-like, yellowish in color. Mucous
membranes exceedingly pale, lips dry and full of
fissures. Eyes bright, pupils not dilafed, react nor-
mally, tongue clean. Chest small, but normal;
lungs negative. Heart's apex in fourth inter-
space inside nipple line. No increase in dulness,
no thrill. A soft systolic murmur heard all over
left chest, loudest at second left interspace. Arm
and legs thin. Abdomen a trifle full. Spleen
and liver readily felt; no oedema. Genitalia not
developed. Stool formed, same characters as
Case I. Very numerous ova found on micro-
scopical examination.

September 27: Thymol given, followed by castor
oil. A small specimen of stool passed at 4 p.m.
seen. All other stools lost.

September 28: Blood count: reds, 4,152,000;
whites, 10,500; haemoglobin, 43 per cent. Stained
specimen showed numerous eosinophils; slight
irregularity in the size of the red cells ; no nucleated
red cells seen. The patient was discharged Sep-
tember 29.

November 10: On microscopical examination
of a specimen of stool many eggs are still seen.
The patient says he never felt better in his life.
He is gaining weight and color.

C.^^sE III. — Harry W., white, Camden Co., Ga.
I am indebted to Dr. Corson for permission to re-

port this case. The patient was bom in Syra-
cuse, N. Y. He was taken by his parents when a
few months old to Camden County, where his
people have since lived. He entered the Savannah
Hospital October 3, 1903, complaining of a gun-
shot wound of the right arm. His parents are liv-
ing and well. He has three brothers and one sister,
all of whom look pale and sallow ; have had repeated
attacks of grounditch, and chills and fever. He
has always been well, except for attacks of chills
and fever, occurring, as a rule, in the fall. He
has had repeated attacks of diarrhoea, but has
never noticed blood or mucus in the stools. His
appetite is good. He goes barefoot, and has had
several attacks of grounditch. He does not admit
much shortness of breath or palpitation of the
heart. He says that near where he lives are many
people who eat pine straw, and are said to eat dirt.
He is sallow, yellowish, anaemic, quite intelligent,
eyes bright, sclerotics have a slightly yellowish
tinge. The conjunctivas are almost white, tongue
slightly coated. A hsemic murmur heard at the
second left interspace, and a palpable spleen which
has a hard fairly sharp edge, are the onl}' points of
interest. The right arm is bandaged from wrist
to shoulder, and is laid on a pillow. He has had a
slight rise of temperature since admission. Oc-
tober 9: A stool obtained was yellowish brown,
homogeneous. On microscopical examination a
number of ova of uncinaria were found. Blood
count: reds, 2,596,000; whites, 9,000; hsemo-
globin, 48 per cent. No malarial organisms found
in fresh smears of blood; some pigment seen. All
red cells are of equal size; eosinophiles not numer-
ous, but appear slightly increased in numbers.
October 10: The patient was given thymol, fol-
lowed by castor oil.

November 10: No eggs were found in the stools
after careful search. The patient has more color
and says he feels better than he has ever felt.

C.'VSE IV. — Gussie M., age fourteen, white. Way-
cross, Ga. Admitted November 12, complaining
of fever. Family history negative. She has always
been well, but has never been very strong. She
has always been pale, suffers from shortness of
breath; has never had diarrhoea; appetite good.
Menstruation began at age of twelve, and has
always been regular and painless. She has had
several attacks of grounditch, the last attack
two years ago. She has never had malaria. While
in South Carolina recently she had dumb chills,
followed by sweats. No vomiting, no nausea,
some headache; loss of appetite. Hyaline asstivo-
autumnal malarial parasites were found in fresh
smears of blood. Temperature on admission was
ioi°F. She was given quinine, and in a few
days her temperature was normal, and has re-
mained so ever since. She is a well-nourished
pale, sallow, girl, fairly intelligent. The mucous
membranes are pale, the sclerotics have a slight
yellowish tinge; pupils normal. Soft systolic
murmur at second left interspace. Large tumor
in abdomen, which is an eight months' pregnancy.
Spleen not felt. Stool examined November 16
was brownish, fairly homogeneous. Numerous eggs
were found on microscopical examination. Blood
count: November 19, reds, 3,920,000; haemoglobin.
55 per cent. Stained specimen showed one cres-
cent; red cells slightly irregular in size; nucleated
red cells seen; no noticeable increase in the eosino-
philes. Patient not to be treated until after de-
livery.

C.\SE V. — This is the case to which I wish par-
ticularly to call attention. It illustrates one phase

July 2, 1904]

MEDICAL RECORD.

of the infection with hook-worms which I have
suspected occurred, but so far have seen but this
one patient. Lina T., age twenty-one, white,
single, was seen on November 10, when she com-
plained of pain in the back, chilly sensations, and
fever. She comes from Screven Co., Ga. Both
parents are dead, causes unknown. She has two
sisters and two brothers living in Savannah. All
are well, except a younger sister, who is pale and
sickly. She has always been sickly, and has never
been able to do much work, as she tires very easily.
She had scarlet fever two years ago; no sequelae.
She had chicken-pox when a child. Up to two
years ago she had grounditch every summer; the
attacks were severe. Menstruation began at age
of fourteen; her periods have always been scanty,
irregular, and accompanied with some pain. She
has had at times a slight leucorrhoea. Occasionally
her feet and ankles have swollen, but she has had
no urinary troubles. She has had some irregularity
of the bowels, and attacks of diarrhoea. Appe-
tite usually good. She works in the American
Cigar Factory here. On November 10 she was
seized with chilly sensations, pain in the back
and loins, and fever. For several days previously
she had been feeling unwell. The pains were so
severe that she was forced to go to bed. She
has had no trouble in passing urine, did not think
it was abnormal in color, and she has had no sup-
pression. Bowels regular, appetite lost. The pa-
tient was seen at night by the light of a small
lamp. She was lying on the right side, and seemed
in pain. A fairly well-nourished girl, but markedly
ansemic, skin pasty white; eyes puffy; mucous
membranes pale; tongue slightly coated; lips
fissured ; the under lip showed herpes, and several
excoriations. Pulse 30 to } regular; low tension;
fair volume. Temperature 101.4° F. There were
a few rales in the lungs at the bases. A loud
systolic murmur was heard all over the left chest
in front; loudest at the second left interspace
over the pulmonary area. No thrill was felt.
The apex beat was inside the nipple line in the
fourth interspace. Abdomen negative, except for
pains in both loins on deep pressure. There was
distinct oedema of both shins, knee-jerks normal.
There was no specimen of urine but the signs and
symptoms were so suggestive of a nephritis that
she was treated as such, and she was told to have a
specimen of urine ready at the visit next morning.
November 1 1 : This morning there is no fever.
The complexion is seen to be sallow, parchment-
like. Her anasmia is seen to be profound. A
specimen of stool was obtained and the suspicion of
uncinariasis was confirmed by finding enormous
numbers of eggs. The stool was exactly like that
described in Case I. Urine examination showed
a clear urine, slight fliocculent precipitate acid,
sp. gr. 1012, no albumin, no sugar. Novem-
ber 13, temperature 99.4° F., pulse 30 to {. The
patient is up and says she feels about as usual.

Blood count showed red cells 3 , 1 60,000 . haemoglobin
27 percent. In a stained specimen one sees that the
red cells stain faintly; they are irregular in shape and
size and show some chromatophilic degeneration.
There is a decided increase in both the eosinophiles
and small mononuclear cells. Normoblasts are
also present. The patient was sent to the Savan-
nah Hospital, where she could be observed and
treated better than at home.

November 14: Temperature 99.6-100* F. Thy-
mol was given in divided doses, followed later by
castor oil. In the stools large numbers of male and
female uncinariae were found. November 16:
Temperature 98.6-99° F. Thymol was again given.

followed by castor oil. A number of worms were
found in the stools. November 18: Temperature
has been normal since last note. Discharged im-
proved. December 20: The patient has gained in
flesh and strength. Eggs are still found in the
stools. She will be given another course of treat-
ment.

These few cases serve to illustrate the point that
I wish to bring out, viz., that in cases of anemia
one should always examine the stools for intestinal
parasites. If the case has come from the country, a
child or young adult, and gives a history of previous
grounditch and attacks of diarrhoea, one is sure to
find eggs of the hookworm in the stools. The num-
ber of eggs found is, as a rule, in proportion to the
severity of the anaemia.

From studies that I have been able to make
around Savannah, I am led to the conclusion that
(i) The anaemias of the country' districts are due in
the great majority of cases not to malaria, but to
uncinariasis; and (2) that in almost all cases of
uncinariasis there have been previous attacks of
grounditch. That the connection between these
two diseases is a close one seems beyond doubt.
The idea was advanced by Looss only two years
ago, tut evidence is daily accumulating tending to
show the intimate relationship between the two con-
ditions. Bentley has found in the water sores of
panighao, which evidently is similar to our ground-
itch, embryos which he identified as those of Aiiky-
lostoma duodenale. That is very significant, and
I believe that when grounditch is carefully studied in
the light of our present knowledge, we shall have
ample confirmation of his work.

Elsewhere I have expressed the belief that
uncinariasis may at times give rise to a fever simu-
lating typhoid or sestivoautumnal malaria. That
there is a long-continued fever in the severe grades,
three of the foregoing cases show. One shows that
an acute exacerbation of a puzzling character may
take place. In such cases it is of paramount im-
portance to make an exact diagnosis, otherwise
whatever treatment we use only temporarily
betters the condition. From the histories and
general appearances, cases of uncinariasis may re-
semble those of pernicious an.-emia. The examina-
tion of the stools alone settles the diagnosis. The
blood conditions in the two diseases may be similar
except for the eosinophilia, which always occurs in
grave cases of uncinariasis. One condition is
easily curable, the other is rarely ever cured.

For a proper interpretation of microscopic blood
changes, however, special training is necessary',
whereas any one who can see through a magnifying
glass can look for and recognize uncinaria eggs under
the low power of a microscope. A small piece
of stool the size of a pin-head is put on a slide and
mixed well with a drop of plain water. On this a
coverslip is dropped and the slide then examined
with Leitz ocular 3, objective 3. In cases of
severe infection one usually focuses immediately
on an egg, and one sees at times ten or a dozen
eggs in one field of the microscope. The whole
procedure takes not longer than a minute, hence no
one should ever be too busy to devote that time
to making an accurate diagnosis on his patient.
This is all the more important when we know that the
treatment is so simple and generally so successful.
Without the diagnosis no treatment is of any
avail that does not attack the cause of the trouble.
With our present knowledge we may be morally
certain of hook-worm disease from the history and
general appearance of the patient, and if there is
no means of verif\-ing microscopically our suspicion,
we can give specific treatment and tell the patient

MEDICAL RECORD.

[July 2, 1904

to look for small, thread-like worms in his stool,
and have him bring a specimen for inspection.
The truth is that we must all laj' aside our precon-
ceived notions that all anaemias and all sallow com-
plexions can be caused only by malaria, if we have
any such ideas, and lay it all to hook-worm in-
fection until we prove any individual case to the
contrarj' after careful stool examination. It is
far better that the pendulum should swing com-
pletely over, and that we should believe all ansemias
to be due to hook-worm infection and none to
malaria, than that we should jog along as we have
done and yearly sacrifice thousands of lives on the
altar of inherent prejudice to new ideas. Let the
profession at present look with suspicion on ground-
itch, preventing it whenever possible, and when
present curing it without delay. Let us take the
attitude of the Saxons that a man is guilty until he
is proved innocent and apply it to grounditch. We
may be mistaken in laying so much stress on an
antecedent grounditch as the cause of hook-worm
disease, but the facts at present at our command
warrant us, in the writer's opmion, in believing
such an hypothesis.

It is also of interest to note that in high grades
of anamia, from whatever cause — neoplasm, hemor-
rhage, pernicious anaemia, uncinariasis, malaria,
etc. — there may be oedema and even anasarca, and
there is in most cases some fever. The fatal termi-
nation is at times preceded by delirium, high tem-
perature, and even mono- or hemiplegia.

The treatment of the cases is simple and success-
ful, although in severe cases it is necessan.' to con-
tinue specific treatment at intervals until the stools
are free from eggs. One gives an adult castor oil
or Epsom salts in the evening. There must be no
food whatever given from then until noon of the
following day. At 8 a.m. 30 grs., 2 grams, of finely
powdered thymol are given either in capsule or
with a little water. At 10 a.m. another dose of
30 grs., followed at noon by a large dose of castor
oil or salts ( 3 I-II). In order to facilitate the
action of the thymol some give whiskey or brandy
with it, but as the combination has proved on several
occasions to possess distinct depressing and toxic
actions, it is safer to administer the drug in capsules
or with water alone.

Finally, let me urge my fellow-practitioners to be
on the watch for cases of anaemia, especially in
children and young adults who come from the
country. I know that some of you do not agree
with me when I lay so little stress on malaria as a
cause of anaemia. I ask you to take careful his-
tories, make, when possible, blood and stool ex-
aminations, and I feel sure that before you have
made many such examinations you will agree
with me that it is the hook-worm that causes, and
has caused, such suffering to our country people.
It is with us in the South a serious economic problem,
and we caimot start too early to band together to
fight it intelligently.

Percussion of the Pulmonary Apices. — Jundell discusses
the possibilities of making errors in doing this, and es-
pecially the fact that percussion is very apt to be carried too
far to one side or the other. He suggests that in percussing
the supraclavicular fossa, a point be selected which
lies just above the clavicle and at the outer border of the
clavicular portion of the stemomastoid muscle. The
finger should be so placed that its volar aspect is directed
backward and only very slightly downward and toward
the median line. When percussing the fossa supraspinata
the same precaution should be taken to place the finger
so that the percussion stroke is at right angles to the
surface of the lung. — Zentralblatt fur innere Medizin.

ACUTE TETAXUS CURED BY INTRANEURAL
INJECTIONS OF ANTITOXIN.

By JOHN ROGERS. Jr.. M.D.,

NEW YORK.

The following case corroborates very strongly the
experiments with tetanus in animals which demon-
strate' the curability of the disease by injections of
antitoxin into the motor nerves of the part primarily
infected.

J. M., a boy of eleven years, sustained a
punctured wound of the sole of the left foot from
a rusty nail. This occurred on the afternoon of
Monday, April 25, 1904. No attention was paid to
the injury, and beyond some soreness no symptoms
resulted until seven daj-s later, or Monday, Maj* 2.
On arising at 6 a.m. this day he complained of some
stiffness about the jaws and neck and was unable
to eat breakfast.

He was brought to Gouverneur Hospital at 10 a.m.,
where examination revealed marked trismus with
risus sardonicus and stiffness and rigidity of the
muscles of the back of the neck. There was a small
punctured wound in the anterior part of the sole of
the right foot just to the outer side of the ball of the
great toe. Pulse no. Temperature 99°. He was
immediately put to bed and given 20 c.c. of anti-
toxin subcutaneously and this dose was repeated in
the afternoon. At 6 p.m. the rigidity of the neck
had extended to all the muscles of the back and the
jaws were tightly closed.

May 3. During the night the condition had
become worse and the apisthotonus was so marked
that he was placed on his back with pillows under
the lumbar and shoulder regions to relieve somewhat
the strain from the backward extension of the head
and legs. At 11 a.m. Dr. Elliot, under whose care
the case had been, kindly consented to allow me to
try the efficacy of the intraneural injections of anti-
toxin which had proved so successful in the previ-
ous case, and therefore under chloroform anaesthesia,
with every antiseptic precaution, the anterior
crurae nerve was exposed just below Poupart's liga-
ment and about 3 ss of antitoxin injected into its
substance. The same procedure was adopted with
the great sciatic nerve opposite the gluteal fold pos-
teriorly. A rather fine needle was employed, and
while the nerve was held on the index-finger the
needle was several times withdrawn and reinserted
into the substance of the trunk to insure some
wounding of the nerve fibers, as experimentally this
seems an essential matter to secure entrance for the
antitoxin. The patient was then turned over and
the needle introduced into the spinal canal between
the lamintE of the second and third lumbar vertebrae.
The needle was manipulated back and forth in the
spinal canal until its motion produced a twitching
of the left leg (the right leg contained the source of
infection). This was intended to make at least an
abrasion of some of the nerves in the cauda equina,
and the twitching was considered evidence of the
success of the manoeuvre. The escaping cerebro-
spinal fluid contained no blood. Antito.xin 3 iss,
was then injected into the spinal canal subdurally.
The wound in the foot was next laid widely open, a
small foreign body, apparently a piece of leather,
and a little pus and necrotic tissue scraped out and
the raw area swabbed with tincture of iodine and
packed with iodoform gauze. A culture made from
the wound was reported later by Dr. Letchworth
Smith, bacteriologist at the Cornell Medical College,
to contain numerous tetanus bacilli. At the con-
clusion of the operation there was found to be a
noticeable relaxation of the rigidity, which persisted
until recovery- from the effects of the anaesthetic
(chloroform). This relaxation occurred with each

July 2, 1904]

MEDICAL RECORD.

subsequent anaesthetization and seemed to me of
appreciable benefit. During the night following (of
May 3) the condition again grew worse and there
were four separate convulsive seizures, each lasting
about ten minutes.

May 4. The condition seemed hopeless; the
opisthotonus was, if anything, worse than in the
previous morning, but there had been no recurrence
of the convulsions noted in the early part of the
night. Not even water could be given by mouth.
The temperature was 103° and the pulse 120. As
the outlook could not be made worse, I decided to
make one more trial of the antitoxin near the
vital centers, and therefore, under chloroform anaes-
thesia, inserted a rather fine needle with a long point
into the spinal canal between the laminae of the
second and third dorsal vertebras. After the needle
was felt to pass between the laminae it was pushed on
until it impinged against the bodies of the vertebrae
in front. In other words, an attempt was made to
puncture the dorsal cord, and though no blood tinge
occurred in the escaping cerebrospinal fluid, I can-
not see how the cord could have escaped some
wounding by the long, fine point. At any rate,
3 iss of antitoxin was injected while the tip of the
needle was felt to toitch the posterior surface of the
vertebral body. The only reaction noted was
marked contraction of the pupils and a slight slowing
of the pulse. Opportunity was taken of the anaes-
thesia to redress and swab with tincture of iodine the
wound in the foot.

During the rest of the day and through the night a
very remarkable improvement took place.

May 5. In the morning it was found that no
convulsions had occurred. The rigidity of the back
and legs had largely disappeared and the mouth
could be opened about half an inch. The improve-
ment was so great that it forced me carefully to
review the previous conditions, and then for the first
time I made the humiliating discovery that in in-
jecting the motor nerves of the leg I had entirely
overlooked the obturator. The source of infection
had probably been entirely eliminated at the first
operation and the charge of poison on its way to the
cord in the two chief nerves, the sciatic and anterior
cruree, blocked, but the charge in the obturator had
been allowed to flow upward and almost produce
death. It had been stopped from reaching the
vital centers only by the antitoxin injected ahead of
it into the upper end of the cord. Whatever the
explanation may be, the value of injecting motor
nervous tissue and of previously producing a wound
of this nervous tissue for the entrance of the anti-
toxin seems to me abundantly proved by the injec-
tion here into the dorsal cord. The condition of the
patient was changed within a few hours from one of
impending death to one of comparative well-being.
And there is the less possibility of exception from
this view because of its close analogy with the ex-
perimental results previously referred to in the
work of Meyer and Ransom.

May 6. The condition of the patient was found
on this day to have deteriorated somewhat from that
noted during the previous twenty-four hours. It
was so excellent on May 5 that no antitoxin had
been given, but on May 6 the trismus had returned
with some stiffness of the neck and back. Liquids
which could be taken freely by mouth yesterday
could not now be managed so well and had again
to be supplemented by rectal alimentation. A
lumbar puncture was therefore performed (under
chloroform) and in manipulating the needle to
wound the nerves there was produced a considerable
flow of blood, perhaps half a drachm mixed with cere-

brospinal fluid. But without waiting for it to cease
Z iss of antitoxin was injected subdurallj'. The
only result noted was contraction of the pupils and
slight slowing of the pulse. During the afternoon
and evening the patient seemed more comfortable
and mouth feeding was resumed.

May 7. The patient seemed perceptibly im-
proved and could separate the teeth about half an
inch. The neck and back were still quite rigid, but
the extremities were entirelj^ relaxed. As no harm
could result, and to forestall any possibilitv of re-
lapse, another dose of 3 iss of antitoxin was ad-
ministered by lumbar puncture. No more was
given subsequently.

May 8. Slow, but evident gain. In the past
twenty-four hours he has been able to roll about in
bed and professed to feel perfectly well if only he
could "cheer."

May 9. The improvement continues, though the
trismus has not entirely disappeared, and did not until
May 13. During the afternoon an extensive
erj-thema began to appear on the abdomen and legs.
On the following day this had spread to involve the
whole trunk and had almost the appearance of
purj^ura hreinorrhagica. But the pulse and temper-
ature continued low, and on May 13 the rash had
entirely disappeared as well as all the symptoms of
tetanus. The wound over the anterior crural nerve
had failed to unite and became infected. The wound
in the sole of the foot was of course granulating and
open. The wound over the sciatic had healed. He
was eating regular house diet, and on May 18 he
was out of bed and pronounced cured.

To my mind the progress of this case has demon-
strated without a shadow of dovibt the efficacy in
tetanus of injections of antitoxin into the substance
of the motor ner\'es of the part of the body primarily
infected and into the spinal cord. From the wonder-
fvil and rapid change for the better noted after in-
jecting the antitoxin into the dorsal cord on May 4
it might be argued that the motor nerves could be
neglected, but in view of the experiments^ by Meyer
and Ransom this would seem unsafe. The ex-
posure of the nerves in the axilla or high up in the
thigh is simple, and adds nothing to the gravity of the
situation, and in the two cases I have reported really
seemed very advantageous. My inexcusable neglect
to inoculate the obturator nerve in this second
case I am convinced led to the increase of symptoms
on May 4. That they were checked by injecting the
dorsal cord only goes to show the necessity of
producing a wound of nervous tissue to secure en-
trance for the antitoxin. This, by the way, is
evidently the crux of the whole problem and seems a
beautiful confirmation of a physiological fact, or
perhaps theorj^ which is as remarkable as it is unique,
namely, the complete isolation of at least some
nerve cells from the circulating blood. • The tetanus
toxin and the antitoxin can only reach these nerve
cells through nervous tissue, and normally this
course begins with the terminal filaments of the
axis cvlinders.

102 E-\sT Thirtieth Street.

Erysipelas and Nephritis. — Nyrop gives the histories of
two cases in which intercurrent erysipelas appeared to
cure or improve an already existing nephritis. The first,
already described by Langeballe, is that of a young woman
suffering from a severe acute nephritis which cleared up
entirely in the course of a moderately severe general
ervsipelas. In the other case the albumin and casts did
not entirely disappear but marked and permanent im-
provement followed. — Zentralblatt fiir innere Medizin,
No. 15, 1904.

14'

MEDICAL RECORD.

[July 2, 1904

THE NON-SIGXIFICANCE OF CLIXICAL
SYMPTOMS IX DETERMINIXG THE PATH-
OLOGICAL COXDITIOXS OF APPEXDI-
CITIS.*

By A. P. STONER, M.D.,

DES MOINES, IOWA.

That the millenium in which the clinical diagnosis
of the pathological conditions of the inflamed ap-
pendix is not attained, is evidenced by the ex-
perience of some of our most noted clinicians and
operators. As one's experience grows with the
diseased appendix, the less inclined we are to
make positive assertions as to the conditions that
will be met on the operating table. After having
operated upon over two thousand cases, Murphy
is quoted by Knott ("Transactions Iowa Medical
Society," Vol. XX) as saying that "he did not
pretend to know anything more of the pathology
of a given case than that the patient had an in-
flamed appendix which should be immediately
removed." Xow and then we meet a case in which
it is indeed impossible to say whether or not the
patient has even "an inflamed appendix." In the
early stages of appendicitis the pains are diver-
sified over the whole abdomen, or may be confined
to the gastric region. These phenomena are ex-
plained by the fact that the superior mesenteric
plexus which supplies the appendix also sends
filaments to the intestines. In some instances
in which a low grade of inflammation of the organ
exists, the pains never become localized around
the appendix, but during each attack or exacerba-
tion of the disease, pain may constantly be ob-
served in the gastric region.

C.\SE I is an illustration of this type. Michael
S., professional gambler, age forty-six; no specific
history. Formerly drank to excess. His infatua-
tion for cards was such that at times he would go
without his meals for from twelve to twenty-four
hours, after which he would grossly overindulge
in food and drink. The trouble for which he sought
relief began about six years ago in periodic spells
of violent pains and vomiting.

The attacks would readily pass away under
proper treatment and leave no apparent trace
of the disorder. He was under my observation
about one and one-half years before the operation.
Usually appearing after a debauch in diet, the at-
tacks would invariably continue until relieved by
opiates. When the stomach was emptied, purging
would ensue. I often found him on the closet
stool with a vessel between his feet, purging and
vomiting at the same time, ejecting by these efforts
only a little mucus or liquids. The accompanying
pains could be compared only with the tortures
of childbirth. Indeed I have seldom witnessed such
agony from any cause. Although at this time he
was not an habitu6, it required from one-half to
three-fourths grain morphine to alleviate his suf-
fering. The attacks came on at varying intervals
of from three weeks to three months, and would
last under proper treatment from two to six days.
Rectal feeding usually had to be resorted to. After
the attack he would be apparently well again and
could eat all sorts of food. No pains or incon-
veniences were experienced between attacks. The
matter vomited was analyzed on several occasions
and usually showed deficiency in hydrochloric acid,
and the presence of lactic acid. At no time, even
during the attack, was there any pyrexia. Pressure
over McBumey's point could arouse no suspicion
of a diseased appendix. The immediate region
of the gall-bladder was apparently normal. Taxm-
♦Specimens presented and cases discussed before the
Des Moines Pathological Society, March 29, 190.5.

dice was never present. Even during the attack the
■ebdomen was always flat, yet no information cotold
be obtained from palpation, etc. The attacks
became so frequent and were of such severity
that the patient became reduced to a mere skeleton
before finally submitting to operation. He had
now become a confirmed morphine fiend, using
from .5 gr. to 1.5 grs. daily. He entered Mercy
Hospital August 15, 1903, and was placed upon
nutrient enemas. Following this he was cautiously
fed by the stomach. It was not, however, until
September 19 that his condition was such as to
permit of abdominal section. Under ether anaes-
thesia I opened the abdomen, beginning at the
costal arch and extending downward three or four
inches along the outer margin of the rectus muscle.
I rather expected to encounter a diseased gall-
bladder. This region, however, was apparently
normal, as was also the stomach and pancreas.
Strangely, the stomach presented no evidences of
the abuse to which it had so long been subjected.
The incision was extended downward to the ap-
pendix, w-hich was found to be slightly enlarged
and injected, and thoroughly adherent to the pos-
terior border of the csecum. After the removal of
the appendix, the wound was closed by two rows of
continuous catgut, and interrupted skin sutures of
silk-worm gut. The belly being scaphoid, some
difficulty was experienced in bringing the walls
of the abdomen together. During convalescence
the patient proved to be extremely incorrigible,
and the day following the operation was found sit-
ting up in the bed. Subsequently he was chastised
a number of times for the same offense. The
stitches were removed on the seventh day, and the
second night following the nurse found him out of
bed sitting upon the commode in an effort to
evacuate the bowels. My attention next day was
directed to blood upon the dressings, and upon re-
moving them, the ghastly spectacle of the abdominal
contents met my gaze. The wound — a seven-inch
incision — had been torn open from one end to the
other. He was again prepared for operation, and
taken to the operating room. It required con-
siderable dexterity and patience to coapt and hold
the edges of the wound together. The tissues had
become softened and the sutures easily cut through.
However, by the aid of through-and-through
sutures of silk-worm gut, which were tied as the
continuous sutures of catgut drew together the
fascia and peritoneum ; the wound was thus finally
coapted. The wound healed a second time by
primary union. The stitches were allowed to re-
main two weeks, and he was kept in bed an ad-
ditional fortnight. It is now four months since
the operation and the patient has gained 40 pounds
and feels perfectly well. He still uses morphine,
however. Although a number of surgeons ex-
amined this patient with me, at no time did any of
us seriously suspect that the appendix was creating
the disturbance.

C.\SE II. — The following case, upon which I
operated a few weeks after the one just related,
illustrates, on the other hand, the paucity of symp-
toms sometimes observed in the most virulent
types of the disease. Mr. S. B. L., age twenty-
seven, was sent me by Dr. Swartslander of Huxley,
Iowa. On Friday, October 31, he experienced
pains in the abdomen, and drove to town to see
his doctor. The doctor found him suffering from
appendicitis, and advised him to return home
and go to bed. On the following Sundaj' some
tympanites developed, and the doctor was called.
A saline purge was administered and the symptoms
rapidly cleared away. Tuesday he was taken five

I Illy 2. 1904]

MEDICAL RECORD.

miles to the railway station in a carriage and brought
to Mercy Hospital in this city, a distance of forty
miles by rail. Examination revealed an induration
over McBurney's point, slightly tender upon pres-
sure. Otherwise his condition was apparently
normal. Indeed, the patient stated that at no
time would he have gone to bed had not his physi-
cian and friends urged him to do so. However, he
was anxious to have his appendix removed, and
on the following Friday, November 6, exactly
seven days from the beginning of his first and only
attack, the operation was undertaken. Upon open-
ing the abdomen, the region of the appendix pre-
sented an apparently inextricable mass of adhesions.
A large mass of partly disorganized omentum, the
thickness of one's hand, was finally released, and
after being tied off was completely removed. In
searching further for the appendix, much more semi-
gangrenous tissue was encountered and cleared
away. Presently I came upon a pocket containing
a mass, the size of a filbert, of semi-solid fecal matter.
It seemed to have been extruded directly from the
cacum, which organ was very much thickened and
scarcely distinguishable from the mass of adhesions
in which it was embedded. After having removed
the fecal mass, and while still laboring under the
impression that the cscum had been opened, I at-
tempted to close up the vent, but the sutures cut
through the softened tissues, and the stitches were
of no avail. What was thought to be the base of
the appendix now became visible, but it was not
possible to extricate the appendix, so thoroughly
was it embedded in the exudate. The opening
being guarded by gauze, a longitudinal incision
was made along the visible portion of the appendix.
The incision included the peritoneal and muscular
coats. The mucous lining was then grasped with
forceps, and while traction was being made, the
incision was prolonged until the other end was
reached; which was found to be the base and to
occupy the posterior border of the caecum. The
supposed rupture of the caecum proved to be a
perforation in the distal end of the appendix. The
core of the appendix having been freed, it was
ligated and the stump cauterized and covered with
peritoneum. The wound was closed without drain-
age. Nothing whatever marred the recovery until
the seventeenth day after the operation, when
thrombosis of the right femoral and saphenous
veins developed. The temperature rose to 101° F.,
the pulse became accelerated, and much pain was
experienced. This annoyance continued until No-
vember 27, when the patient was again permitted
to be out of bed. He left the hospital November
31. To my mind it is almost a mystery how the
insignificantly inflamed appendix in Case I could
have been responsible for the profound symptoms
manifested. It is none the less mysterious how-
one could be up and about doing farm-w-ork with
such a condition as was revealed in Case II. The
deduction to be drawn from Case I is that a slightly
diseased appendix may be responsible for a variety
of symptoms that may be attributable to other
organs. Case II furnishes additional proof that
no case, however apparently mild, should be en-
trusted to nature or drugs.

Large Doses of Carbolic Acid in the Treatment of Plague.

— Dr. J. C. Thomson gives particulars of 141 cases of
plague treated -svith large doses of carbolic acid. One hun-
dred and forty-four grains were given daily, divided into
two-hourly doses of 12 grains each. The mortality among
those so treated was only 36.4 per cent. — Journal of
Tropical Medicine.

HYGIENE IX GYNECOLOGY.*

By C. a. von RAMDOHR, M.D.,

-S'EW YORK.
PROFESSOR EMERITUS NEW YORK P0ST-GR.1DUATE MEDICAL SCHOOL;
FELLOW OP THE .NEW YORK OBSTETRICAL SOCIETY; NEW YORK ACADEMY
OF MEDICINE. ETC.

In all branches of medicine hygiene is considered
the most important factor in combating the source
of disease, and so it is primarily in gynecology.
Secondarily, hygienic treatment is the most valua-
ble therapeutic agent in wrestling with women's
troubles.

Therefore, to oust the gynecologist from his
present status as curative agent we must primarily
prevent women's diseases by attention to women's
hygiene.

Starting from the very beginning the connubial
bliss enters our consideration. Marriage between
minors, between people, one of which is syphilitic,
between near kin, between people who are by nature
of their poverty unable to rear their young, ought
to be prevented, if possible. For part of their off-
spring would naturally only appear as natural
weaklings, always complaining of very natural
woes, while the other would be forced by circum-
stances to enter the race of life before they are phy-
sically able, and thereby show themselves as phy-
sical wrecks in our general clinics.

The influence which crowded quarters with their
inherent absence of cleanliness and morals have
upon the female child are well recognized. The
consequence of bad morale is well known. The
habits of the young girl deteriorate, and moral
turpitude may be traced directly to the surround-
ings. Not only does the poor young female child
suffer from want of care of the mind in her morally
corrupt atmosphere, but her body is not properly
cleansed; her clothes are insufficient; her food
is not well up to the standard in calorics, and last,
but not least, by the attitude of her poor parents
she is prevented from attending school "whenever
that may be," to cure an insufficient degree of ig-
norance which will be propagated on the next
generation. Their interest will lie in making the
little girl a self-supporting wage-earner at as early
a date as the lax law will permit. Bent over the
shuttle, or bending over other work like sewing,
sewing in a sweat-shop, or working in crowded fac-
tories for abnormal hours, the little girl lays the
foundation of future sickness.

Still wealthier parents' girls are hardly any better
off. The bottle cannot equal a mother's nourish-
ment and care. Children's balls are not conducive
to a better standard of womanhood. A fashionable
school will not help to raise the morale or the phy-
sique of a fashionable girl.

Thus, in trying to avoid, or make other people
avoid any of the previous delicto of hygiene
we stand as gynecologists on the point where we
ought to stand regarding the prevention of women's
troubles by hygiene.

Now, supposing that we get in contact with a
patient suffering from some female trouble, let us
remember the great axiom "Mens sana in corpore
5aMci," and as a corollary: Nulltis uterus (^-\- adnexa)
nisi sanus in corpore sano. Ergo Mens sana =
Uterus sanus, i.e. a healthy body contains a
healthy mind, and a healthy uterus (and adnexa).

To the greatest extent our patients suffer from
subjective symptoms — they complain of pain,
and consequently their nervous system is affected.
They must be treated in a surgical way if necessary,
or by medical therapeutics, either by medicinal
agents or by hygiene.

♦Paper read at a meeting of the New York Obstetrical
Society.

MEDICAL RECORD.

[July 2, 1904

The first thing for us gj'necologists is to make a
thorough and complete diagnosis. By exclusion,
by objective examination, the cause of our pa-
tients' trouble ought to be established, should such
require surgical interference — for example, for
tumors benign or malignant, pus collections, re-
pair of lacerations, removal of degenerated mu-
cous membrane, dilatation, dislocation — in fact,
anything that would objectivelj' show a degenerated
organ or interference with normal functions — well
and good, let our proper surgical demanded work
precede all other curative measures, always keeping
in mind that this is done for a subjective painful
symptom for which the patient is likely to consult
us, and which we are trying to relieve.

But these are not surgical procedures but make-
shifts, if we remove organs not unhealthy, diagnosed
because patients complain of pain in their respec-
tive regions.

We are past the period of clitoridectomy, past
the period of oophorectomy and salpingectomy,
past even the period of nephropexy, and last, but
not least, indifferent curettage for subjective
symptoms only. I say, we are, I mean the Eastern
gynecologists, and the people in the West, South,
or North who are abreast of the profession.

Only lately I came across a female wreck, who
had been carved by a St. Louis artist, and after
four operations had both her kidneys anchored,
appendix, uterus, and adnexa removed, and who
begged pitifully for the relief of pain for which
she originally consulted her physician. All opera-
tions make a strong impression on the woman's
mind, relieve her of her complaint, but onh' for a
certain time.

Massage of the uterus and adnexa so grandly
introduced have failed, except in certain selected
cases. The rest cure has only lately fallen asleep.
Hypnotism and suggestion. Christian Science, and
hydrotherapy, and Kneippism are looked on through
different spectacles from formerly. Nowadays
each up-to-date g\-necologist tries the newest fad,
i.e. electricity in one or the other forms. But
if the nerve specialists acknowledge that this thera-
peutic agent will only act curativelj' in 25 per cent.
of their cases while 75 per cent, are benefited only
by the sensations, what is there in gynecology to
permit the indiscriminate application with a view
of curing the disease? We may relieve symptoms
but not cure the cause. Let us now consider the
local treatment of uterine affections. Deviations
of the uterus which produce painful symptoms
or may be the cause of sterility will, of course,
be benefited by restoring the organ to its original
position.

As we know that almost a majority of copulating
women's troubles are the result of the gonococcus,
God bless our confrere Noeggerath for his inven-
tion, and Lawson Tait for his original technique —
the local effort of stamping out the cause will be
of the highest importance. Hot or cold douches
for inflammatory troubles plus glycerin tampons
cannot be dispensed with. Whether paintings
with one or the other agent for plain endometritis
are of any but impressionable advantage, I have
my serious doubts.

Medicinal agents are good either as a placebo
or as aperients or ferruginous compounds, as most
of our patients are subject to anaemia and consti-
pation. Ergot has prevented many a fibroid opera-
tion, but of all others, practically, I have my doubts.
Knowing that all aches and pains (and it is
primarily the object of finding relief from those
that the gynecologist is consulted) are the result of
sensitiveness, and as sensations are relative and
a subjective symptom which cannot be appre-

ciated objectively by any other person, and know-
ing that otherwise healthy women are least sensi-
tive comparatively, therefore, a course of general
treatment can only conduce to the health of the
individual — that is, in our case to the female patient.
This general treatment is called hygeine. Any
and all women will be benefited, and some will be
restored to health and happiness.

Being consulted b}' a patient, and having heard
her complaint, which practically will consist of pains
in the back or abdomen, leucorrhoea.etc. after having
carefully excluded heart, kidney, lung trouble, etc. ;
after having carefully excluded a diseased or mis-
placed genital organ which might need surgical
or local treatment, it behooves us to inquire care-
fully into the marital relations, the mode and
frequency of coition, the means taken to prevent
conception, and remedy whatever is possible in
this direction. To go into details would be an
insult to your intellect.

The house surroundings and mode of living
ought next to be studied: whether the patient
is kept too warm, or too cold, whether the fresh air
supply is sufficient (open windows, ventilators,
heating apparatus, etc.); what an amount of care
she takes in the household management, or what
work she performs, what food she partakes of or
craves for, the hours of meals, the recreations —
reading, for example, the theater, balls, parties,
or athletic exercises, etc., what stimulants she
partakes of. or what narcotics (alcohol, coffee,
tea, tobacco, morphine, chloral, bromine, etc.),
and in what quantities. The care of the skin and
teeth is next in order, and last, but not least, her
mode of dressing: shoes, heels, corset, underwear.
That her stools ought to be attended to is self-un-
derstood; also the general care of the period of
menstruation; ditto the support of a pendulous
abdomen.

Once more I only need mention these points to
remind you of their importance.

There is but one point more to which I would call
your attention. Physical exercise is usually over-
done, unless carefully prescribed and superintended.
Six-ounce dumb bells are better than two-pound
ones. A walk of half a mile is better than one
of several miles if it tires the patient.

It is with this graduated and superintended
hygiene that the well-known watering-places in Eu-
rope obtain their stupendous results. In the treat-
ment of females: Absence from home influences
and the husband; fresh air, baths, and spongings
carefully administered ; carefully prescribed exer-
cises, attention to diet and digestion, early hours —
all these hygienic measures do more toward curing
a patient of her symptoms than long continued
local or symptomatic treatment indiscriminately
employed.

4S Irving Pl.^ce.

Typhoid Fever and Its Treatment. — B. A Bobb present
the following conclusions: (i) Typhoid fever is self-lim-
iting disease which can often be modified and shortened
in its course, and often aborted if treatment is instituted
early in the course of the disease. (2) Where early elim-
inative, antiseptic and hydro-therapeutic treatment is
instituted there is not the dry tongue after the first few
days. The tympanites is absent or nearly so, and there
is not the exhaustive diarrhoea. (3) The temperature is
easily controlled by sponge baths. (4) There are cases
wherein complications develop that will call for a most
careful study of the case in question. (5) It is the dvity
of every physician who has cases of typhoid fever in charge
to use e\ery prophj'lactic measure to prevent those who
have the care of patients thus afflicted from contracting
the disease. — The Medical Herald, March, 1904.

July 2, 1904]

MEDICAL RECORD.

Medical Record:

A Weekly Journal of Medicine and Surgery.

GEORGE F. SHRADY, A.M., M.D.. Editor.

THOMAS L STEDMAN, A.M., M.D.. Associate Editor.

PUBLISHERS
WM. WOOD & CO., 51, Fifth Avenue.

New York, July 2, 1904.

COLLEGIATE TRAINING OF WOMEN.
There has arisen among civilized women within the
past few years a great desire to compete with men in
whatever callings of life are open to both sexes.
This new departure on the part of women has been
especially noticeable in the United States. In order
to qualif}- themselves to meet men on anythin.g like
equal terms in the battle of life, women have rec-
ognized the fact that they must, as far as is possible,
be well equipped for the ira.y. Consequently female
colle,ges have sprung up like mushrooms in all parts
of this country. To a lesser extent this statement
is true also of Great Britain. As to the wisdom of
this course opinions are greatly divided, but the
weight of evidence would seem to show that women
in encroaching upon fields which have hitherto been
occupied solely by men. on the whole, have been ill-
advised. Of course, it is well understood that some
women must go out of their own groove of work and
earn their livings outside their homes. It is, how-
ever, a grave question as to whether this tendency
has not been carried to excess, and whether the race
has not suffered, at any rate in America, through
women deserting their domestic duties for a life
which is contrary at least to the traditions of their
sex.

Is a collegiate training harmful to women? The
rwajority of medical men are of the opinion that such
is generally the case — at all events, that co-education
is harmful to women — and hold the view that women
are not fitted physically for the strain put upon them
by strenuous professional or business careers.

Inthe Edinburgh Medical JoitrualioTMaiy, 1904, Dr.
T. Claj-e Shaw deals with this matter from his own
point of view, which it may be asserted is probably
the point of view of nine-tenths of the medical pro-
fession. The writer points out that those best able
to judge of the evils of college training for women are
medical men attached to such institutions, and their
experience is to the effect that stress of competition
presses in too indiscriminate a way upon the young
women who are brought together and educated in
very large numbers. In the opinion of Dr. Shaw, the
forcing system in vogue in colleges both for men and
women at the present time is good neither for the
quick-witted nor for the moderate or dull girls.
The former, indeed, perhaps suffer the most, for
their readiness at work and the pressure that is put
upon them to accomplish an end at all risk, though
at times compassed with impunity, often ends in
disaster and evil after-consequences. The writer
also thinks that the resiilts of these distressing efforts
to compete with man on his own ground are de-

cidedly barren. A few succeed in their university''
curriculum, and may be said to have found their
true metier, but, in the words of Dr. Shaw, " It does
seem as if the altruistic and sympathetic side of the
woman's character is destroyed by the process of the
new education, which substitutes a cold formalism
for the warm spontaneity which dominates the
majority of the sex."

If women desire a university education they
should be separated from men in their work, as in
addition to the competition in intellectual pursuits
the entire trend of co-education is toward the
elevation of the pureh intellectual, and the disregard
of the emotional side of the character, thereby un-
fitting the woman for her natural vocation, that of
motherhood and of caring for her children and
home. While a few women succeed in competing
with men on the same plane of mental endeavor the
majority are more or less failures, their training on
the lines of co-education, not having benefited
them a jot, indeed rather the reverse.

Dr. G. Stanley Hall, the eminent Americarr
psychologist, has recently published a work on
"Adolescence, " a part of which treats of its relations
to education. In a consideration of adolescent"
girls, and their education from a medical standpoint,
the author quotes largely the opinions of medical
men on the subject, some of which will be noticed
here. Dr. Storer urged that girls should be educated
far more in body and less in mind, and thought
delicate girls frequently ruined in both body and
mind by school. Dr. Clarke, in 1873, wrote a book in
which he pleaded that woman's periods must be
more respected. This work appeared at the height
of the movement to secure collegiate opportimities
for girls, and was suspected of being unofficially
inspired by the unwillingness of Harvard University
to receive them. It reached a seventeenth edition
in a short time, but the views expressed therein were
warmly combated by a number of ladies distinguished
in the movement for the higher education of women.
Clouston has, in various articles and books, ex-
pressed himself in very trenchant terms. In the
United States, Clouston thinks that most families
have more or less nervous taint or disease; that
heredity is weak because woman has lost her cue,
althou.gh nature is benign and always tends to a
cure if we have not gone too far astray, but, he adds,
"There is no time or place of organic repentance
provided by nature for sins of the school master.
A man can work if he is one-sided or defective, but
not so a woman. "If she be not more or less
finished and happy at twenty-five, she will never be."
Parents want children to work in order to tone down
their animal spirits, and it almost seems to Clouston
as if the devil invented school for spite.

Dr. S. Weir Mitchell has so often given out his
views on the question, that they are well-known.
Woman, he holds, is physiologically other than man
and no education can change her. Grant Allen said:
"In any ideal community the greatest possible
number of women must be devoted to maternity and
marriage, and support by men must be assumed and
not female celibacy. The accidental and exceptional
must not be the rule or goal. This is only a pis
allcr. It is not so much the unmarried minority
that need attention as the mothers. We must
not abet woman as a sex in rebelling against ma-

MEDICAL RECORD.

[July

1 904

temity, quarrelling with the moon, or sacrificing
wifehood to maidenhood. "

Le Bon pleaded that the education we now give to
girls consists of instruction that fits brains otherwise
constructed, prevents womanly instincts, falsifies
the spirit and judgment, enfeebles the constitution,
confuses their moods concerning their duties and
their happiness, and generally disequilibriates them.
Sir James Crichton Browne holds that differences
between sexes are involved in every organ and tissue,
and deprecates the present relentless zeal of inter-
sexual competition, concerning the results of which
it is apalling to speculate from a medical point of
view. When the University of St. Andrews opened
its theological department to women, it was not a
retrograde movement, because our ancestors did no
such thing, but a downhill step fraught with con-
fusion and disaster. He quotes with approval
Huxley's phrase that "what has been decided among
prehistoric protozoa cannot be annulled by act of
Parliament." Prof. A. W. Small thinks that to
train women to compete with men is like poison
administered as a medicine, the evils being quite as
bad as the disease.

So far as co-education is concerned, Dr. Stanley
Hall thinks that while the system is not so harmful
in college and still less harmful in universit}'' grades
after the maturity which comes at eighteen or
twenty has been achieved, it is high time to ask
ourselves whether the theory and practice of
identical co-education, especially in the high school,
which has lately been carried to a greater extreme in
this country than the rest of the world recognizes, has
not brought certain grave dangers, and whether it
does not interfere with the natural differentiations
seen everjnvhere else.

The consensus of expert opinion is against the
higher education of women carried to extremes, and
particular!}' adverse to co-education. The weighti-
est argument against too much mental stimulus for
women, is the fact that educated women, and
especially highly educated women, are less fecund
than their more ignorant sisters. Herbert Spencer
was authority for the statement that "absolute or
relative infertility is generally produced in women
by mental labor carried to excess. " According to
Dr. Hall, this has probably been nowhere better
illustrated than by college graduates. He says
"Excessive intellectualism insidiously instils the
same aversion to 'brute maternity' as does luxury,
overindulgence, or excessive devotion to society.
Just as a man must fight the battles of competition,
and be ready to lay down his life for his country,
so woman needs a heroism of her own to face the
pain, danger, and work of bearing and rearing
children, and whatever lowers the tone of her bodv,
nerves, or morale so that she seeks to escape this
function, merits the same kind of opprobrium which
society metes out to the exempts who cannot or who
will not fight to save their country in time of need. "
The ordinary' woman's true place is her home, and
by far her most important duty to the race and to
the State is the bearing and bringing up of children.
Her educational training should at least not unfit
her for the proper performance of this essential
service. It is claimed, and undoubtedly with much
truth, that the modem system of education does
tend in this direction. Consequently, the system

should be altered. If by a continuance of the
present methods of educating women, the birth rate
of those countries in which such methods are
practised will inevitably decrease, it can be clearly
understood that the game is not worth the candle.

DIAGNOSIS OF TOPHI IN THE EAR.
The differential diagnostic characters of tophi in the
ears is discussed by Dr. Wilhelm Ebstein in a recent
number of the Deiitsches Archiv fur klinische Mediziv..
Strangely enough, there seems, the author tells us.
to be no very accurate description of tophi in the
books. The question is then under what circum-
stances one is justified in considering a nodule in the
ear as referable to the group of tophi, and therefore
proof of the existence of gout. The best description
is that given by Garrod, who says tophi are some-
times single, sometimes numerous, sometimes smaller
than a pin head, sometimes larger than a split pea.
The}' generally have the appearance of pearls, and
usually lie on the borders of the helix. As regards
consistency they are sometimes hard and sandy, but
frequently soft and yield a milky juice on puncture.
Since Garrod's time little in the way of description 01
them seems to have been attempted. As to their
significance, they are regarded as the exclusive
property of the gouty. Thus Duckworth has found
them in one-third of his cases (forty-nine out of 150).
and as their appearance frequently precedes the
arthritic manifestations of gout, their presence has
acquired a diagnostic value that can hardly be over-
estimated.

In the course of the preceding year Ebstein has
seen, in three cases, formations in the ears which
resemble in many ways, and therefore . require
differentiation from the true gouty tophi, from
which they are separated by the following characters :
First, their seat is neither in the cuticle, nor in the
subcutaneous connective tissue, but in the cartilagi-
nous tissue itself; and, secondly, no uratic contents
can be obtained from them. The first of the cases
was that of a man, with gradually increasing joint
pains, and old tuberculous lesions at the apices, who
presented on the antihelix sharply bounded, hemis-
pherical elevations, 4 mm. in diameter, with a hard
feel, which yielded on puncture no fluid, the tumor
being solid. The left knee-joint was 3 centimeters
larger in circumference than the right, and the
patellar bursa contained fluid which was drawn three
times but never contained uric acid or urates. The
second case, a man of thirty-two, developed the
tophi-like bodies while under intermittent ober\-a-
tions extending over years. The helix and antihelix.
tragus and antitragus, exhibited a series of promin-
enceswhich.on puncture, yielded fluid not containing
uric acid or urates. The mother was under treat-
ment for chronic gouty arthritis. The third case
was one of typical uratic gout, without typical tophi
an}-where; prominences of cartilaginous consistence
were present in the ear cartilage itself.

These observations, though few in number, never-
theless yielded a viewpoint that deserves attention.
Grouped, the observations yield the result that
rheumatic, and goutily-burdened individuals, tophi-
like nodules mav be present in the ears which do not
correspond to the gouty deposits frequently occur-
ring there, not being like the ordinar}- tophi, seated
in the subcutaneous tissue, but lying in the cartilages

July 2, 1904]

MEDICAL RFXORD.

themselves. The\- appear to be generally of firm
consistence, not deviating from that of the cartilage.
Whether they bear a relation, and if so what relation,
to rheumatism and gout, is an open question. This
much, however, may at least be said, that in no
case should one make a diagnosis of tophi, and there-
from of the presence of gout, unless he obtains
uratic contents from the ear tumors.

Memorial to the L.\te M.wor Walter Reed.

It is proposed to erect in the city of Washington,
a suitable memorial to Walter Reed, Surgeon U. S.
Army. For this purpose the Walter Reed Memorial
Association has been formed and has further been
incorporated under the general laws of the District
of Columbia, to give unity to the various proposals
which have been made for the securing of a Memorial
Fund. The officers of the association are: Presi-
dent, D. C. Gilman, LL.D., Vice-President, General
G. M. Sternberg, LL.D; Treasurer, Mr. Charles L
Bell; Secretary, General C. DeWiU. U. S. A. The
executive, committee is composed of the following:
Major L R. Kean, Surgeon, U. S. A.; Major W.
D. McCaw, Surgeon, U. S. A.; and Dr. A. F. U.
King.

There are many and obvious reasons why the late
Major Reed's memory should be perpetuated by the
building of an appropriate monument. One reason
is that physicians, whose benefits to the human race
have been, perhaps, greater than those of any other
profession, have been less often honored during
life or after death than members of any other pro-
fession. Again, medical men of the United States
have not been greatly distinguished in original
scientific research, so that when an American
surgeon has made a discovery such inestimable
importance as the cause of yellow fever, it is fitting
that the discoverer should receive every possible
recognition.

Although Dr. Carlos Finlay of Havana, several
3'ears ago, had advanced the theory that a mosquito
convej^ed the yellow fever to man, he did not suc-
ceed in demonstrating the truth of his theory. It
remained for Major Reed to prove fully bylaboratory
and practical experiments that such was indeed the
case. The principal conclusions of the board of
investigators, of which Reed was the leading spirit,
were: (1) The specific agent in the causation of
yellow fever exists in the blood of a patient for the
first three days of his attack, after which time he
ceased to be a menace to the health of others. (2)
A mosquito of a single species, stegomyia fasciata,
ingesting the blood of a patient during this in-
fective period is powerless to convey the disease to
another person by its bite until about twelve days
have elapsed, but can do so thereafter for an in-
definite period, probably during the remainder of
its life. (3) The disease cannot in nature be
spread in any other way than by the bite of the
previously infected stegomyia articles used and
soiled by patients who do not carry infection.

The application of methods suggested by these
conclusions resulted in the virtual extirpation of the
yellow fever in Havana, and like means may be
relied upon to have correspondingly efficacious
effects in localities in which yellow fever is rife.

It may be anticipated that it is but a matter of
time when yellow fever will be known no more.
That the discovery made by Reed is one of the
first importance, must be clear to all. He was
assuredly a benefactor to mankind at large, and as
such his memory should be kept green. The medical
profession throughout the country, military and

civil alike, should haste to do honor to the name
of Reed.

Work of the Public Health and Marine-hos-
pital Service.
The annual report of the Surgeon-General, re-
cently issued, gives the doings of the Marine-hospital
Service for the fiscal year 1903. A part of the
report is devoted to the sanatorium for consump-
tives established by the service at Fort Stanton,
\ew Mex. Two hundred and seventy-four pa-
tients have been treated at the sanatorium during
the year, an excess of 62 over the previous \-ear.
There were 12 discharged, recovered; 54 discharged,
improved; 10 discharged, not improved; 150 re-
mained under treatment during the year. The
treatment has been, on the whole, attended with
very beneficial results, but as Surgeon P. M. Car-
rington, the surgeon in charge, remarks, patients
leave too soon. He thinks that greater control
should be exerted over the patients in this respect.
It is therefore suggested that Congress be asked to
pass a law which will enable the service to enlist
these patients for, say, a period of one year, or to
make other written agreement with them, with
appropriate penalty for breach of contract on the
part of the patient, granting authority to the com-
manding officer to arrest or otherwise restrain those
desiring to leave without his consent prior to the
termination of their enlistment or contract.

Regarding the plague, the report states that cases
of this disease have continued to appear in the Chinese
district of San Francisco, thirty-eight cases being
reported during the fiscal year. The aid afforded
the municipal authorities has been continued, and
this joint work has no doubt served to confine the
disease to its original limits. No case of j-ellow
fever was reported in the United States during the
fiscal year 1903, while Cuba has continued to be
free from the disease.

Dviring the fiscal year 857.046 immigrants were
inspected by the officers of the service as to their
phj'sical fitness for admission, as prescribed by the
immigration laws. One officer has been stationed
at Naples, and another at Quebec, in the interest of
the medical-inspection service. Examinations are
conducted at thirty-two ports in the United States,
and on account of the large number of immigrants
entering at New York, Boston, Baltimore, Phila-
delphia, New Orleans, and San Francisco medical
officers have been assigned to dut}^ at these ports
exclusively for the examination of arriving aliens.

At the close of the fiscal year the commissioned
corps of the service consisted of 109 officers, as
follows: The surgeon-general, 6 assistant sur-
geons-generals, 24 surgeons, 27 passed assistant
surgeons, and 51 assistant surgeons. At the close
of the fiscal year there were 179 acting assistant
surgeons, including seven appointed for duty at
fruit ports of Central America whose service will be
terminated at the close of the quarantine season.
During the fiscal year the scope of the hygienic
laboratory has been increased with the additional
features contemplated by the act of July i, 1902.
The Division of Zoology has been organized and the
organization of the Division of Pharmacology is in
progress. The Division of Chemistry will be or-
ganized at a later date. The work of the laboratory
has been along lines pertaining to public health,
examination of water supplies, a study of the action
of various disinfectants and germicidal agents,
the investigation of diseases and conditions of
sanitary and economic importance.

Among the contributed articles in the report is an

MEDICAL RECORD.

[July 2, 1904

excellent one by Passed Assistant Surgeon J. C.
Perry on the epidemic of cholera in the Philippine
Islands during 1902.

The Localization of Tabetic Lesions.
In the Paris letter of the Albany Medical
Annals, for May, 1904, reference is made
to Pierre Marie's article in the Revue Neu-
rologiqtie on this subject. Marie's article is
probably the best exposition of the matter that
has ever been given. The Paris school of neu-
rology has made immense studies of late, and our
knowledge of nervous pathology has been greatly
increased by the laboratory work of men like
Brissaud, Marie, Babinski, and others. The meeting
of the " Societe' Neurol ogique " on the first Thurs-
day of every month is an event in scientific circles,
for no meeting passes by withotit papers of the high-
est interest being read and earnestly discussed.

Marie, in his paper on "The Localization of
Tabetic Lesions," proposed to explain this locali-
zation, by bringing into play the h^mphatic dis-
tribution of the spinal meninges. He has noticed
that in early tabes, the topograph}' of the patches
of sclerosis does not always coincide with the intra-
medullary course of the posterior nerve-roots,
and therefore thought that this relationship was
more apparent than real. For him the sclerosis
of the posterior columns is not the extension of the
process observed in the posterior nerve-roots, but
is dependent upon, and limited by, the lymphatic
supply. From the investigations of several ob-
servers and by laboratory experiments made by
Marie himself and others, it is evident that the
posterior columns, their meninges, and the posterior
nerve-roots have a special lymphatic system, the
"posterior lymphatic system," constituting in
itself an anatomic entitj', Marie consequently
believes that the lesions of locomotor ataxia can be
best explained by admitting that the morbid process
is one of h'mphatic origin and distribution. Marie
ends his paper by saying that "The initial lesion of
locomotor ataxia is a syphilitic lesion of the pos-
terior spinal lymphatic system."

The primary cause of tabetic lesions has ever
been of the greatest interest to the neurologist.
Recently a certain amount of doubt has been cast
upon the widely held belief that to syphilis must
be attributed the origin of locomotor ataxia. The
conclusions therefore of so eminent a student of
nervous pathology as Marie cannot but carry
much weight.

Military Sanitation in the Japanese Army.
The Japanese have afforded to a somewhat wonderf
ing world an excellent object lesson on the value o.
military organization and preparation for war
So well have they imitated and assimilated Western
methods and ideas, that probably no European
army is superior while more than one is inferior to
that of Japan as regards equipment and organization.
This is the case, too, with sanitary and medical
affairs. The first evidence of the State of high
efficiency to which the Japanese had brought their
military medical organization was in the war with
China in 1894. In the Journal of the Association of
Military Surgeons of the United States for June,
Lieutenant - Colonel John Van Rensselaer Hoflf,
Deputy Surgeon-General, U. S. A., ctdls attention
to this almost forgotten fact. The writer quoted
from writings of the present Director General
of the British Royal Army Medical Corps, who
was at the time of the Chino-Japanese war at the
scene of conflict. The then Colonel Taylor says
in part: "At Port Arthur there were opportunities

of seeingjhow every part of the medical machine
worked. . . . Lives were saved on the spot where
the men fell, by the prompt application of tour-
niquet and even large arteries were ligatured under
heavy fire. . . . The wounded were removed from
the field without any delay just as quickly and quietly
as they always were on the bi-weeklj- parades
of the bearer columns in time of peace. If regi-
ments were engaged far ahead, the regimental
bearers did the work until the bearer companies
came up, when they again took their places in the
ranks. There was no loss of time, the medical
men were ever)'where. "

So little news of the war has been ailowed to leak
out by the Japanese authorities that only the main
facts are known. However, it may be taken for
granted that the Japanese Military- Medical Depart-
ment has upheld the reputation it gained for itself
in the war with China, and has successfully vied
with the army in fulfilling its duties. There is no
doubt that if the war with Russia is long protracted
that there will be an immense amount of disease
with which to deal. When the rainy season sets in,
considering the insanitarj^ state of the towns in
Manchuria, typhoid fever will become rife, and
it is not unlikely that plague and beriberi may
attack the troops. Beriberi is a disease to which
the Japanese are susceptible, and plague is a malady
more prevalent in China than in any other country.
The work before the medical organizations of both
Russian and Japanese armies bids fair to tax
their respective capabilities to the utmost, but,
judging from the accounts of the Japanese Military
medical service, it should, at least, be relied upon
to cope with an}' situation presenting itself with
credit.

Nrhis nf the Berk.

Medical Congress at St. Louis. — The plan and
purpose of the Medical Department of the Congress
of Arts and Science at St. Louis deviate so far from
traditional lines that some explanation may be
necessary to show how it should interest the medical
profession. It is primarily a congress of scholars
rather than of specialists. It is divided into
twenty-four departments, one of the strongest of
which is medicine. The Department of Medicine
is divided into twelve sections, embracing the
principal fields covered by the subject. These do
not include Embryology. Anatomy, Physiology, or
Bacteriology, as these subjects are embraced in
in the Department of Biology. The Department of
Medicine will be opened on Tuesday, September
20, under the chairmanship of Dr. William Osier,
with two general addresses by Dr. W. T. Council-
man of the Harvard Medical College and Dr.
Frank Billings of the Rush Medical College. One
of these speakers will review the progress of medicine
during the past centurj-, and the other will treat its
fundamental conceptions.

On Wednesday morning, September 21, a section
of Public Health will meet under the presidency of
Dr. Walter Wyman, Surgeon-General of the U. S.
Public Health and Marine-Hospital Service. It
will be addressed by Prof. W. T. Sedgwick of the
Massachusetts Institute of Technology and Dr.
Ernst J. Lederle, formerly Commissioner of Health
of New York City. Communications relating to
the subject are also expected from several eminent
members of the profession. A section of Otology
and Laryngology will meet at the same time:
Chairman, Dr. Glasgow of St. Louis; Principal
Speakers, Sir Felix Sermon of London and Dr. J.
Solis-Cohen of Philadelphia.

July 2, 1904]

MEDICAL RECORD.

In the afternoon a section of Preventive Medicine
will meet, under the chairmanship of Dr. Mathews,
President of the Kentucky Board of Health. It
will be addressed by Professors Ronald Ross of
Liverpool and Celli of Rome. Some question has
been raised against the advisability of separating
the sections of Preventive Medicine and Public
Health. This separation is, however, of no practical
importance, as all interested may equally well
attend both. On the same afternoon a section of
Pediatrics will meet under the chairmanship of
Dr. Rotch. and will be addressed by Escherich of
Vienna, Jacobi of New York, and others.

On Thursday morning, September 22, there will
be meetings of sections of Pathology and Psychi-
atry. The chairmen of these sections are Drs.
Simon Flexner and Edward Cowles respectively.
Marchand of Leipzig and Orth of Berlin have
accepted invitations to address the section of
Pathology, but it is not certain whether both will
be able to attend. Psychiatry will be treated by
Ziehen of Berlin and Dana of New York.

In the afternoon a section of Neurology will meet,
under the chairmanship of Prof. L. F. Barker of
Chicago, and will be addressed by Kitasato of
Tokio and Putnam of Boston.

The sections which will meet on Friday and
Saturday, September 23 and 24, are as follows:

Therapeutics and Pharmacology. Chairman:
Dr. Hobart A. Hare of Jefferson Medical College.
Speakers: Sir Lauder Brunton, F.R.S., of London
and Prof. Mathias E. O. Leibreich of the University
of Berlin.

Internal Medicine, Friday afternoon. Chairman:
Prof. F. C. Shattuck of Harvard University.
Speakers: Prof. Clifford Allbutt, F.R.S., of the
University of Cambridge and Prof. William S.
Thayer of Johns Hopkins University.

Surgery, Friday morning. Chairman: Prof. Carl
Beck of the Post-Graduate Medical School, New
York. Speakers: Prof. Frederic S. Dennis of
Cornell Medical College, New York, and one other
not finally selected.

ffj'wecoZogv. Saturday morning. Chairman: Prof.
Howard A. Kelly of Johns Hopkins University.
Speakers: Dr. L. Gustave Richelot, Meinber of the
Academy of Medicine, Paris, and Prof. J. C. Webster
of Rvish Medical College, Chicago.

Ophthalmology, Saturday afternoon. Chairman:
Dr. G. C. Harlan of Philadelphia, Pa. Speakers:
Dr. Edward Jackson of Denver, Col., and Dr.
George M. Gould of Philadelphia, Pa.

One of the two principal speakers in each section
will treat of the relation of the subject to other
departments of knowledge; and the other of its
present problems. Besides the principal speakers
it is expected that each section will receive several
brief communications from leading members of the
profession in attendance at the meeting. It will
be seen that the division into sections is one of
subjects rather than of men. The chairmen and
speakers will be different in different sections, but
the attendance, it is expected, will be the same,
except in the sections holding their meetings at the
same time

The California Medical Practice Law. — The
Supreme Court of California has recently rendered
a decision in a test case upholding the constitution-
alitv of the law establishing the State Board of
Medical Examiners. The decision not only declares
the law constitutional in every respect, but approves
of its object and affirms the need of such regulation
of the practice of medicine in terms so emphatic
as to effectualh" discourage all future attempts to
evade the law.

University of Southern Cahfornia.— The gradua-
tion exercises at the Medical Department of the
University of Southern California, Los Angeles,
were held on June 14. The degree was conferred
upon twenty-four members of the class. A most
enjoyable banquet was participated in by the
faculty, graduating class and alumni, at the Angelus
hotel in the evening. On the following Thur'sday
the corner-stone of a new clinical laboratory building
was laid. This is to be one of the best equipped
laboratories in the West and will cost $200,000.

The Annual Sacrifice. — The New York Times says
that the State Board of Health of Pennsylvania
has communicated to the Mayors and Burgesses of
every city and township in the State a memorandum
calling attention to the need of a better enforcement
of the law relative to the sale of toy-pistols and
high explosives. It makes the assertion that the
recorded casualties last year from the use of toy-
pistols, giant firecrackers, and explosive toys
during the Fourth of July celebration were 4,349
injuries and 466 deaths, or more than the Russian
casualties in killed and wounded during the recent
two days' fighting at Hai-Cheng. Its tabulated
record of injuries and deaths last Fourth of July
makes the following showing of totals:

Died of tetanus caused by injuries 406

Died of other injuries 5^

Totally blinded jo

Number who lost one eye - r

Arms and legs lust ". -'^

Number who lost fingers 1-4

Number injured who recovered 3.983

Total number of casualties in the United States . . 4,349

Warning against Yellow Fever.— Dr. Taber, the
Commissioner of Health of Texas, has sent an
official communication to the Governor requesting
the latter to issue a proclamation warning the
people of the State of the imminent danger of a
yellow-fever epidemic if they neglect the first
principles of cleanliness and sanitation in their
houses and communities. On account of the open
winter of 1903-4 in southern Texas and the prev-
alence of yellow fever in Mexico at present, he
says he greatly fears that should a case be introduced
into the State with the present very bad sanitary
condition of a large number of the cities and towns
and the presence of the yellow- fever mosquito,
which also exists in large numbers throughout the
State, there will be the most extensive epidemic of
yellow fever ever known. He therefore urges the
Governor "to issue a communication calling upon
the county judges, mayors, and health officers of
Texas to inaugurate sanitary campaigns in every
community in the State without delaj', especially
for the destruction of the mosquitos."

The Manhattan Eye and Ear Hospital, which has
been located for many years at Forty-first Street
and Park Avenue, is to have a new home next door
to the Baron Hirsch Trades School in East Sixty-
third Street. The capacity' of the present hospital
is fifty ward patients, with eight rooms for private
patients. It is proposed to construct eventually
on the new plot buildings which will accommodate
about four hundred ward patients and fifty private
patients.

Exhibit of Johns Hopkins Hospital at the World's
Fair. — The Johns Hopkins Hospital has placed a
display in the Educational Building at the St.
Louis Exposition. It is unique as being the only
demonstration of nursing work among the exhibits.
The exhibit consists of a series of photographs
showing the hospital' exterior, views of the interior,
groups of student nurses at work in the labora-
tories, class-rooms, and wards. Models of nursing
appliances in operation, with specimens of charts,

MEDICAL RECORD.

[July 2. 1904

etc., are intended to give an idea of the opportunities
for nurses and the results of their training.

Sanitary Responsibility of Property Owners.—
The Health Commissioner of St. Louis received a
decision from the City Counselor in regard to the
responsibility of agents, property owners, and
tenants in cases in which insanitary conditions
exist. The opinion of the Counselor states that an
agent is never responsible e.Kcept in cases in which
he has power of attorney; that where more than
one family occupy the premises, if the tenants are
compelled to use toilet facilities in common, the
owner should be held responsible ; that if the prem-
ises are occupied by more than one family and
there are separate toilet facilities for each family,
the persons using these accommodations should be
held responsible for their sanitary condition, be
they owner or tenant.

An International Congress of House Sanitation. —
The Societe d'Hygiene Franfaise has issued a call
for an international congress to study the present
hygienic conditions of dwellings and to devise means
for their amelioration. The investigations and
discussions of the congress will cover dwelling-
houses in city and country, laborers' cottages and
tenements, hotels, lodging houses, schools, and the
living quarters on steam and sailing vessels. The
work of the congress will be distributed among six
sections, embracing the subjects above mentioned.
The membership fee is fixed at 20 francs ($4).
Those intending to present communications to the
congress should forward the manuscript to the
secretary -general not later than September i. The
President of the congress is Dr. Janssen; the Secre-
tarj^-General, Dr. F. Marie Davy, 7 Rue Brezin,
Paris.

First Toy-pistol Victim. — Walter Booth of Cin-
cinnati was trephined June 25, at the City Hospital,
for tetanus resulting from a toy-pistol wound.
This is the first case in Cincinnati since the passage
of the ordinance last March forbidding the sale of
the toy-pistol.

Cocaine Habit in Cincinnati. — Despite the fact
that stringent laws were passed by the Ohio Legis-
lature lastjwinter regulating the sale of cocaine, it is
said that the sale of the drug in Cincinnati is larger
now than ever before. It is sold principally on the
levee and in the sections of the city where the
dissolute congregate. It has been reliably estimated
that 350 ounces of cocaine, of a value of about
S6,ooo, is sold every month to this class in Cincinnati.

National Guard of Pennsylvania.— Dr. Joseph K.
Weaver of Norristown has been promoted from
Division Surgeon to Surgeon-General, replacing Dr.
Robert G. LeConte of Philadelphia resigned. Dr.
George H. Halberstadt of Pottsville has been
reappointed Surgeon of the Third Brigade, and Dr.
T. C. Biddle of Ashland has been appointed
Assistant Surgeon of the Eighth Regiment.

Commencement Exercises of Rush Medical Col-
lege. — This college, which is affiliated with the
University of Chicago, held its commencement
exercises June 15, at which time degrees were
conferred on a class of 107. The Doctorate Address
was delivered bv Dr. Chas. G. Stockton of Buffalo,
N. Y.

Increased Endowment. — The Chicago-Farmington
Society held a lawn fete in Winnetka, 111., recently,
at which $2,000 was raised to complete the endow-
ment of the Sarah Porter room in the Passavant
Memorial Hospital.

Smallpox in Chicago. — Since the first of January
there have been eightj'-nine cases of this disease

discovered in Chicago, and removed to the Isolation
Hospital, and it is said of these not a single individ-
ual had been properly or recently vaccinated.
Two patients died, seventy-six were discharged as
recovered, and eleven were still under treatment.

Dr. John B. Murphy was recently elected President
of the Chicago Medical Society

Hospital Needed. — Dr. Chas. E. Humiston of
Austin, 111., urges the establishment of a hospital at
some point midway between Austin and Oak Park.
The two villages have a population of fifty thousand,
a id the nearest hospital is four miles away.

New Hospital at Kewanee, 111. — In the new St.
Francis Hospital, Kewanee, organizations and
individuals have already agreed to furnish twenty-
one out of the twentj-'four private rooms. Dr. L.
A. Westgate has decided to sell or close the Syca-
more Hospital, which has not been a profitable
institution.

Physicians for Elks' Reunion. — Forty physicians
have been appointed lur service during the Elks'
Reunion to take place in Cincinnati this week.
Thej- will serve without expense to the city, and
will be uniformed in white with red crosses on
sleeves.

Dr. Russell Hulbert. — The report recently pub-
lished in the daily press and in these columns that
Dr. Hulbert had escaped from a sanatorium at
Green's Farms and walked to Higganum, was
incorrect. Dr. Hulbert had left the sanatorium
and was at his parents' house in Middletown.
One day fee walked from Durham to Higganum for
the sake of exercise, and this was the only founda-
tion for the report as published.

Pulmonary Diseases in the Street-sweepers of
New York. — Street Cleaning Commissioner Wood-
bury made public a few days ago the result of his
medical examination of the sweepers of the de-
partment. He was aided in this work by ten
physicians of the Health Department. Out of a
total of 1,872 men 283 were found to be afflicted
with pulmonary complaints. Of this number only
60 had tuberculosis. The consumption scare in
the Street Cleaning Department came about two
months ago, when the department's doctors dis-
covered that more than 25 per cent, of those who
applied for sick leave were suffering from this
disease. By the time the news reached the
public it had taken growth, and the statements
were made that a quarter of the entire street-
cleaning force had consumption. The men be-
came alarmed for their own safety, thinking that
their work must be particularly dangerous, and
their fears were not quieted by the discussion in
the press of the peculiar dangers to which it was
assumed they were exposed, despite the fresh-air
theory of the prevention and cure of the disease,
r. Obituary Notes. — -Dr George L. Fitch, a native
of New York State and of late a resident of San
Francisco, died suddenly at Santa Cruz, Calif., on
June 2. From 1880 to 1885 Dr. Fitch served as
the Crown physician of Hawaii. In this capacity he
made a study of leprosy on Molokai.

Dr. Ch.'VRLES S. Woodw.^rd of thiscity died at
Glens Falls on June 26, of pulmonary tuberculosis.
He was bom in Michigan thirty-five years ago,
and was graduated from the Xew York Univer-
sity Medical School in the class of 189 1. He was
a member of the New York State Medical Associa-
tion.

Dr. Jons- F. Bird died a* Fox Chase. Philadelphia,
on June 23. at the age of eighty-nine years. He
was graduated from the Medical Department of

july 2. 1904]

MEDICAL RECORD.

the University of Pennslyvania in the class of 1843.

Dr. Julius J. Strecker died at Johnstown, Pa.,
on June 23 at the age of fifty-three years. He was
graduated from Jefferson Medical College in the
class of 1878. He was President of the Board of
Health of Cambria County and Vice-President of the
Cambria County Pharmaceutical Society.

Dr. Dennis J. Tre.icy died in Philadelphia on
June 20 at the ageof sixty years. He was graduated
from Jefferson Medical College in the class of 1867.

Dr. James Simpson died in Philadelphia on June
20 at the age of sixty-five years. He was a student
at Jefferson Medical College when the Civil War
broke out, receiving appointment as an Army
Surgeon and being placed in charge of the hospital
corps at Alexandria, Va. At the close of the war
he concluded his medical studies and was graduated
from Jefferson College in the class of 1865. He was
for several years chief physician to St. Mary's Hospital.

Dr. J.'iMES M. Clement died of pneumonia in
Philadelphia on June 12, at the age of seventy-one
years. He was graduated from the Medical Depart-
ment of the University of Pennsylvania in the class of
1862.

Massage of the Heart for Chloroform Collapse. — W. W.

Keen states that on only three occasions in his entire profes-
sional life has he had a patient die on the table. The first
two were cases of operations on the brain and goiter
respectively. Hemorrhage was the cause of death in
both cases, all the usual means being unavailing. The
third case was especially interesting for several reasons.
This patient had previously had a fracture of the skull
from which he had entirely recovered. He later suffered
from squamous epithelioma of the vocal cords. At the
first operation unilateral laryngectomy was performed,
partly under local ansesthesia and partly under chlorofortn.
The latter produced marked cyanosis. At the second
operation, total laryngectomy was performed. Chloro-
form and oxygen were given to the patient, but not until
he was upon the operating table. When enough chloro-
f rm was given to keep him quiet he became so cyanosed
as to make the writer very anxious for his life. Just as
the wound was ready to be closed his pulse suddenly failed
and his face became suddenly blue. The operation : nd
the administration of chloroform were immediately
stopped. Strychnine was given hypodermically, pure
oxygen was administered, and artificial respiration was
instituted with rhythmical traction on the tongfue. The
battery was applied over the phrenic, but in spite of all
this treatment, his heart continued to beat much faster
and weaker; he became more cyanotic, and in two or
three minutes he was dead. After continuing the above
means for about ten minutes as a last resort the upper
abdomen was opened and the writer introduced his hand
into the abdominal cavity, and between this hand and the
right hand, which made counter-pressure on the anterior
wall of the chest, the heart was massed. These efforts
were continued for nearly half an hour, but without
avail. The writer then reports a case which came under
Igelsrud's care. The operation was that of abdominal
hysterectomy. There was chloroform collapse. The
writer laid bare the heart by a resection of parts of the<
fourth and fifth ribs. The pericardium was opened and
the heart seized between " he thumb and fore and middle
fingers on the anterior and posterior surfaces. Strong and
rhythmical pressure was made for about one minute when
the heart began to pulsate of itself, but as the pulsations
became weaker, massage of the heart was practised for
about one minute more. From that time the pulse was
perceptible and the contractions of the heart became
regular. The patient recovered. The writer gives an
interesting resume of work by various authorities on this
subject. — Proceedings of the Philadelphia County Medical
Society, March 31, 1904.

OUR LONDON LETTER.

(From Our Special Correspondent.)

HOSPIT.\L SUNDAY SPONGE LEFT IN ABDOMEN, ACTION

FOR DAMAGES CENTRAL MIDWIVES' BOARD'S ABSURD-
ITIES — DIRECTOR-GENERAL NAVAL MEDICAL DEPART-
MENT — king's college HOSPITAL TUNBRIDGE WELLS

HOSPITAL NURSING ASSOCIATIONS — L. L. JENNER.

London, June ir. 1904.
We are on the eve of Hospital Sunday, and great efforts
are being made to equal and, if possible, to surpass the
last year's collection. That was the record year (,464,-
975). Some hope to make it £"100,000 this year. Mr.
George Herring has again promised to add one-fourth to
the amount collected up to £100,000. Last year his
cheque was £12,302. The Lancet has again issued a
special supplement for distribution, and the Lord Mayor
has made the usual appeal. Mr. Charles Morrison has
sent in £1 ,000 to be added to the fund.

An action against a lady doctor was concluded on
Tuesday in a way which seems fraught with serious
consequences for the profession, while it controverts
the received doctrine of negligence. A patient, on
whom the doctor had performed an abdominal opera-
tion, brought the action for damages in consequence
of a sponge having been left behind. The judge, in
summing up, said there was no doubt that the oper-
ator was a skilful surgeon, but the question was
not as to her skill but whether she had been guilty of
want of reasonable care. He put the following questions
to the jury: (i) Was the defendant guilty of want of due
and reasonable care in respect of the counting or superin-
tending the counting of the sponges? (2) Was the nurse
employed to act as defendant's assistant during the opera-
tion.' (3) Was the nurse guilty of negligence in counting?
(4) Was the counting of the sponges a vital part of the
operation? (5) Was the nurse under the control of the
doctor during the operation? The jury after a long de-
liberation, answered all five questions in the affirmative
and assessed the plaintiff's damages at one farthing.
The judge pointed out that this was inconsistent with the
findings on the other questions and the jury again retired
to consider that point. On returning they said they did
not think this was a case for damages, as the operation
had been performed by the defendant without any fee.
Finally, they declared plaintiff ought not to have more
than £25, and that only in consideration of her suffering.
Judgment was accordingly entered for that amount and
costs.

Several questions are being talked about in reference
to this case. It seems to traverse the general view that
professional service is not to be accounted as negligent
if ordinary skill and care be exercised. Special or expert
skill is not the oft'er of the ordinary professional man.
It is not improbable that much discussion on this point
will take place.

Another question arises as to the liability of a doctor
who renders a service without fee or reward. Should a
patient who accepts gratuitous aid have a right to dam-
ages for unskilful or negligent treatment? If this is
to be recognized as law, surgeons will become more chary
of taking such cases, or may think it necessary to protect
themselves by obtaining an indemnity beforehand, in
case of a mischance occurring.

It would seem that those who leave counting sponges
to the nurse are yet responsible for her errors — a decision
which may serve to check the tendency to hand over to
nurses duties for which they are not fitted. This applies
to many points in practice. If a miscount by a nurse
is to saddle the doctor with damages, the position becomes
more serious.

Another point was raised in a conversation the other
day, VIZ., was the doctor in this case a member of one
of the protection societies? Some said if not, she did
not deserve pity. For ten shillings a year a kind of
insurance can be entered into against the pecuniary
consequences of such a misadventure. The defence
would be undertaken by the society of which the doctor
was a member, and would probably be more successful
than when conducted by lawyers, without special experience.

The last question reminds one that the annual meeting
of the Defense Union was held on the 26th ult.. when
a very satisfactory report was presented. In the past
year over 1,000 cases had been submitted for the council's
consideration, besides many others which had been dealt
with by the secretary. This shows the great risk that
is run by practitioners in various ways. The cases that
go to the solicitor are about 150 per annum. Some
remarkable statements were made as to attempts at black-
mail defeated by the intervention of the union, and
of slanders or libels retracted and apologized for as soon

MEDICAL RECORD.

[July

1904

as the accusers found the defence^iWasjh the hands of a
society.

The proposal of the British Medical .Association to
absorb the Defence Union was repudiated, and the meet-
ing determined to "maintain the integrity of the union
in its entirety as at present existing. " . „ ,

You know how the apathy of the profession allowed
the Midwives' Act to pass — an apathy which many now
lament. The Central Midwives' Board— the product of the
act— has now resolved to invite rep rters to its meetings.
This is, so far, well, for hitherto the proceedings of the
board have been characterized by ignorance and prejudice.
So much so that Dr. W. J. Sinclair of Manchester, an
independant member of the board has felt constrained
to expose some of its doings. This eminent professor
accepted a seat, but has not been able to secure the co-
operation of the other medical members, and as a con-
sequence the lav members have utterly ignored the
profession — or rather, so far as they can, placed it in
a position of inferiority to the midwives' calling. Thus,
they have actually prop'osed to appoint a "trained woman"
as an inspector of institutions applying for recognition.
That such inspection would be useless, that it would be
an insult to the medical staffs and, through them, to the
whole profe«ion to sertd a midwife to report on their
teaching, was of no consequence. The n>idwife interest
carried it — and that because three out of four medical
members, to their shame be it said, declined to vote
At the next meeting the degradation of the profession
is to be carried a step further by a proposal to appoint
matrons or midwives of lying-in hospitals as examiners.

Many coimty councils have appointed their medical
officers" of health as executive officers for the adminis-
tration of the act. How will these M. O. H.'s, most of
them highly qualified practitioners, relish the idea of
their work "being inspected by midwives or their teach-
ings reported on bv matrons?

You will reme'mber how this board lately pro\-ed
its incompetence by refusing to recognize the Dublin
Schools of Obstetrics, which are notoriously the
most efficient in these islands and perhaps in Europe.
At the same time the London Obstetrical Society's
diplomas were recognized as also a numljer of institutions
\\-ith no pretense to be more than local lying-in charities
But the board has now capped all its former exploits by
a resolution that "it is desirable that Mrs. H — — should
be certified, as it appears from her letter that she is quite
prepared to take a case alone." This woman's letter
stated "that she had not undertaken cases without doctors,
but had been advised by a medical man that she need not
be afraid to do so and she did not feel afraid of so acting.
•The resolution is in direct defiance of the board's onvn
rules, and will serve as a precedent for any woman cer-
tifying herself as not afraid to act as a midwife.

All this scandal arises, as I have said, from the apathy
of the mass of the profession and the readiness of a few
men-midwives' to sacrifice the interests of their brethren
to the "Midwives' Institute, " a small trades-union of Mrs.
Gamps.

Inspector-General Herbert M. Ellis, R. N., has been
selected to succeed Inspector-General Sir H. F. Xorbury,
K.C.B., who will shortly retire, as Director-General of
the Navy Medical Department.

The Duke of Connaught has accepted the presidency
of King's College Hospital in succession to the late Dulce
of Cambridge.

Last night there was a grand fancy ball at the Albert
Hall on behalf of the removal fund. It was organized
by the Countess of Pembroke, and a large number of the
smart set attended and a great success was attained. The
peculiarity proposed and largely carried out was for the
ladies to adopt a fancy head-dress.

Tunbridge Wells Hospital has been enlarged at a cost
of £25,000. The new buildings comprise male and female
wards of twenty-four beds each, children's ward, isolation
ward, and additional out-patients' accommodation. Ten
thousand pounds has been raised and a bazaar was
opened on Tuesday in aid of the fund.

The report of the Affiliated Benefit Nursing Asso-
ciations for the Supply of Cottage Xurses, presented at
the annual meeting on Wednesday, stated that 138 societies
are now comprised in the organization, that the balance
sheet is satisfactorj-, and that the demand for the benefits
of the association is increasing.

The Colonial Nursing Association's annual meeting
on Wednesday was graced by the presence of Princess
Henry of Battenburg and a distinguished company.
Mr. Chamberlain was among them, and a reprint of his
article in the North-American Review was distributed.
This association has 109 nurses at work, 89 haxing been
selected at the request of the government. Earl Grey
said the association was filling the r61e and almost the
dignity of a department of State and deserved the support

of every public-spirited individual. The Duke of Marl-
borough added that the Colonial office constantly received
evidence of its usefulness.

The first annual report of Lady Dudley's scheme
to establish district nursing in the poorest parts of Ireland
has just appeared, and in a rather attractive form. There
are photographs of the districts where the nurses are at
work. Nine nurses have been placed in cottages, or in
lodgings in poverty-stricken places, and are doing a great
work in ministering to the suffering poor. To extend the
system only funds are needed, and for such help the com-
mittee appeals.

The death of Louis L. Jenner. M. B. O.xon.. of the Lister
Institute of Preventive Medicine, at the early age of
thirty-eight, occurred on the 2d inst. He was the fourth
son of the late Sir William Jenner, Bart., G.C.B.

OUR LETTER FROM THE PHILIPPINES.

(From Our Special Correspondent.)

SANITARY PROBI.BMS NEED OF AN EFFICIENT PERSONNEL

LACK OF FUNDS — lo.N'ORANCE OF THE NATIVES — OPPO-
SITION OF THE LANDLORDS OUTLOOK PROMISING DE-
SPITE OBSTACLES.

M.\KiLA, May 26, 1904.

The question of an efficient personnel for the execution
of sanitan,' work is a very troublesome one. The number
of available physicians is totally inadequate to meet medi-
cal and sanitary needs, and there are some four hundred
municipalities in the islands having organized governments
which have no local boards of health, for the reason that
there is not a single physician or undergraduate in medi-
cine living in any one of them. Clearly, without the
advice of any medical man being available, any efforts at
local sanitation in such towns must be inefficient, and
proper statistics as to causes of mortality will be unobtain-
able. This deficiency in the number of medical men is one
that can only be remedied by the education as physicians
of a much larger number of young men than are now
matriculating at the single medical school in the islands;
the best that can be done to minimize the evil effects of
such deficiency is to cause frequent inspections to be made
of towns having no such boards of health by provincial
and insular health officers. A higher standard of medical
education should also be required. Xot a few of the native
physicians present marked professional deficiencies, not so
much through their own fault as through the absence of
modem facilities for their education. Manila is the only
place in which there is a sufficiency of doctors, but there is
no small difficulty in inducing these to take positions in
the provinces, where they would be surrounded by a pop-
ulation regarding them with more or less distrust as for-
eigners and with whom they would have little that is con-
genial. For the minor sanitary positions there is less diffi-
culty in securing satisfactory service, for the Filipino leams
his part readily in the performance of routine and can
carry out directions even when unable to initiate the
proper action in an emergency. One trouble with this class
of minor employees is that they are too apt to assume
undue importance in their official positions and commit
abuses liable to bring the whole sanitary service into dis-
repute. The employees of all grades, as a whole, require
frequent inspection to keep them up to the efficient per-
formance of a reasonable amount of work. In any medi-
cal emergency of any importance in the provinces, assist-
ance and supplies must usually be sent to the local author-
ities from Manila, subject to the common annoying delays
due to poor transportation facilities and deficient means
of communication.

Another obstacle to health work is lack of funds. The
proportion of the appropriations allotted to this purpose is
satisfactory, but with the inception C)f sanitary work it
was found that the investment of a vast amount of money
in permanent sanitary improvements was necessary.
Nothing of a sanitary nature was inherited from the Span-
iards. In spite of the desire to limit outlay, many changes
were imperatively demanded, and in Manila alone the
attempt to convert it into a modem city, from one of the
sixteenth century, in the brief space covered by the Ameri-
can occupation, would have bankrupted the inhabitants.
Sanitary growth in other parts of the world is gradual,
while here proper sanitation meant a complete remodeling
of everything done up to that time. Tasks must be under-
taken as a whole which in other countries would simply be
continued over long terms of years. With a country left
impoverished bv war and pestilence, the revenues were
naturally unsatisfactory and the appropriations for sani-
tary purposes suffered accordingly. The only remedy
available is found in greater financial prosperity, and in
the time necessary to accomplish the sanitary changes
required.

Ignorance is a great bar to sanitary work. A large part
of the population is illiterate, and some 600,000 of them

July 2. 1904]

MEDICAL RECORD.

-3

are savages. The amount of assistance in sanitary work
which would be given by naked, head-hunting, and ghost-
worshiping savages is naturally not great. It is useless
to appeal to their intelligence and reason from the basis of
modem medical science, for the latter is absolutely
unknown to them and totally opposed to tribal teachings
and customs. Even among the more intelligent Filipinos
it is difficult to make many understand that sanitary sci-
ence is based on accurate knowledge; they are unwilling
to disinfect in cholera because they cannot see the bacilli,
yet they pray for relief from the epidemic to an invisible
San Roque. One great reason for ignorance on sanitary
matters is the total absence in the past of any literature
on the subject in the native languages, the lack of any
such information in Spanish and the failure on the part of
the Spaniards to give any instruction in such matters.
Here a great opportunity is afforded for the inception of
a sanitary educational propaganda, through the wide cir-
culation of bulletins on health matters couched in simple
language and printed in the various native tongues, and
through the teaching of elementary hygiene throughout
the public schools. Such an educational propaganda, effi-
ciently conducted, should bring about more iinmediately
satisfactory results than could be obtained in any other
way, and is the best means of advancing sanitation at the
present time. The board of health is already proceeding
along these lines, both by the education of health officers
in a practical school in Manila and the circulation of a
vast amount of literature on health matters.

In Manila the chief objections to sanitary' work now
come from the wealthy householding class, who are unwill-
ing to pay the bills for the sanitary remodeling of their
unwholesome tenements. These bills have been very
heavy, as naturally would be the case in a city where prac-
tically everything was wrong from a sanitary standpoint.
This wealthy class has fought sanitary reform in every pos-
sible way, and has only lately come to the conclusion that
compliance is necessary and that sanitary laws were made
to be enforced. The poorer classes have lately come to
understand that these sanitary reforms are much to their
advantage and mean greater comforts and conveniences
of life for them. A noticeable change has lately occurred
in the much greater frequency with which these people are
calling the attention of the sanitary authorities to unhy-
gienic conditions, and requesting their abatement. The
working classes are rapidly learning that health is their
most valuable asset, and the householding class that an
insanitary tenement is not a good investinent.

On the whole, sanitary work here has every drawback
met with in civilized communities, besides many obstacles
of which the sanitarj- officer in the United States has no
conception, and the importance of which can only be appre-
ciated through extended personal experience. Neverthe-
less, the outlook for considerable sanitary progress in the
early future is very promising. As far as the provinces go,
sanitary advance must depend to a considerable extent
upon commercial development and prosperity and the
higher type of general civilization attached thereto.
Ignorance and superstition are to be combated by educa-
tion, racial dislike overcome, and distrust superseded by
confidence. The guiding hand should be firm, yet diplo-
macy will be required and important sanitary problems can
never be considered as apart from politics. The Filipino
is readily susceptible to kindly handling, and a little tact
and consideration will remove opposition that force could
not brush aside. Many reforms cannot be carried out in
an ideal manner; under such circumstances one must be
contented with the best results which it is possible to
obtain. Continued opposition along any given line is best
met by temporary cessation of pressure until the people
have become accustomed to the new order of things, when
the advance may be resumed. Larger funds for sanitary
expenditure will be available as the country recovers from
the effects of war and epidemic, while experience will add
to the efficiency of the sanitary personnel. Nevertheless,
it is too much to expect that provincial conditions here
will at any early date approach those of rural communities
of the same size in the United States. With the exception
of Japan, however, it is equally true that another decade
should see provincial conditions here better than in any
other part of the Orient. With regard to the city of
Manila, sanitary improvement should be even more rapid.
Much is now being done in the way of house repairs, grad-
ing, draining, filling, and the opening up of new means of
communication. Work is shortly to be commenced on the
new water supply, and it, with the drainage and sewerage
S5'stems already planned, should be completed within three
or four years. Cholera has been banished, plague cut
down, and special attention given to the infant mortality.
The health work is constantly being broadened as oppor-
tunity offers and funds permit. In view of all this, there
is no reason why Manila shall not share with Havana the
honor of feeing the healthiest citj' in the tropics, and show
a lesser mortalitv than manv communities at home.

ELECTRICITY APPLIED TO THE DENUDED
PERICARDIUM OVER THE VENTRICLE IN
HEART FAILURE: A SUGGESTION.

To THE Editor op the Medical Record:

Sir: As a possibly successful means of resuscitation in
sudden heart-failure I would suggest laying bare the
pericardium over the left ventricle and applying electricity
at the bottom of the wound.

The usual failure of electricity applied over the pra-
cordium to excite cardiac action is probably due in large
part to the very .great electrical resistance of the in-
tegument and the subcutaneous fascia characteristic of
those structures. This resistance dissipates the current
through a wide area, and necessitates such intensitv of
action as endangers deeper-lying nerve centers. With
onlv the two layers of the pericardium between the
electrode and thecardiac muscular fiber it should be easy,
theoretically at least, to provoke contractions by a rela-
tively feeble current, particularly if concentrated upon a
limited area by the use of a small electrode.

Moreover, the possible importance of this power of
Hmiting and controlling the action -nail be apparent whin
we consider the possibly disastrous effect of including the
inhibitory nerves in the'electric stimulation.

As a "last resort, electric-puncture nto the muscle
substance might be tried, the surface of the heart being
practically already exposed. Incidentally there would
be an advantage in being able to note slight ventricular
movements, of which there would be no indication if the
chest-wall were intact.

Andrew H. Smith, M.D.

18 E.\sT Forty-sixth Street. \ew York. June 20. 1904.

THE PRESENT STATUS OF THE SURGICAL
TREATMENT OF CHRONIC BRIGHTS DIS-
EASE.

To the Editor of the Medical Record.
Sir: An article bearing the above title, from the pen
of Dr. A. A. Berg, which appears in the issue of yoiir
valued journal of June 18, has interested me. In this
article the writer engages in the laudable attempt to base
the indications for "medical and surgical therapy upon
the variety of nephritis present. For this purpose he
arranges all cases of nephritis according to their etiology,
under eight groups. As illustrating types of these groups.
Dr. Berg details six cases ; three of his own, two of Rovsing
and one reported bv the writer. A few not unimportant
errors have crept into the report of the case last named;
to correct these is the purpose of the present communi-
cation. . , , ...

Dr. Berg writes: "As evidence of the bacterial m-
fection producing different lesions in the kidneys of the
same patient, the following history is quoted from Ede-
bohls : In the one kidney are all the evidences of chrome
Bright's disease, in the other multiple abscesses." Now,
as a matter of fact as well as of record, both kidneys
were the seat of chronic Bright's disease, and both kidiieys
were, in addition, affected by pyelonephritis with miliary

Next follows an abstract of the history of my case as
originally reported in full in the Medical Record of
December 21, 190 1. In the course of his abstract. Dr.
Berg states: "After the operation (right nephrectomy)
the patient's condition improved, and she gained flesh
and strength, but her urine contained albumin and casts
Gradual evidences of chronic Brighfs disease developed
and Edebohls performed decapsulation on the remaining
kidney." This again is a misunderstanding on the part
of Dr. Berg possibly due to hurried or careless reading
of mv original report, where it is distinctly stated that
the nephritis from the patient's last pregnancy, while
infection of both kidneys occured only sometime after
delivery. In other words, the case represented an in-
stance of bilateral chronic parenchymatous nephritis with
subsequent infection of both kidneys. The order of
events was as follows: Chronic nephritis during entire
last pregnancy, which terminated at tefm on tebruary
12, 1901. Persistence of chronic nephritis after delivery
Hysterectomy for sloughing uterine fibroma, March 17
1 90 1. Acute" proteus infection of right kidney a month
later. Right nephrectomy for acute pyelonephritis w^ith
miliary abscesses. July 9, 1901- Persistence of left
chronic nephritis and of pyuria. Decapsulation of left
kidney, November 10. 1901. t c 1

While the above errors are perhaps explicable, 1 hr I
it difficult to account for the following statement of Dr.
Berg, on page 996: "Edebohls' case (cited above) of
bilateral bacterial nephritis in which one kidney w-as
removed and decapsulation performed upon the remain-
ing one, was only temporarily improved, the patient finally
succumbing to the disease." Not only has she not sue-

.MEDICAL RECORD.

[July 2, 1904

cumbed, but at the present wriling, more than two years
after decapsuJation of the kidney, the patient is in the
enjoj'ment of practically perfect health. This gratify-
ing state of afiEairs has been reached after stead}' progress
toward health during the past two years, a progress
apparently continuous even at the present time. A trace
of albumin, with a very occasional hyaline cast and
leucocyte, are all the indications that remain of her former
serious condition, while the patient has long ago resumed
her duties in hfe, has absolutely no complaints of any
kind, and considers herself a perfectly well woman.

I am possibly as deeply interested as any physician or
surgeon in the solution of the problems of the surgical
treatment of chronic Bright's disease. Articles of the
scope and aims essayed by Dr. Berg are particularly
welcome and appreciated, especially if based upon per-
sonal experience, as is the case in part at least in the
present instance. So much keener is the disappointment
when the validity of deductions and conclusions made and
drawn are practically nullified by the incorrectness of
the premises upon which they are based, and especially
when such mistakes in the premises might, as in the
instance before us, have been so readily avoided.

Whether other avoidable errors have crept into Dr.
Berg's paper I am not prepared to say. Of imavoidable
errors, that is, errors into which Dr. Berg's personal
experience has perhaps not been sufficientl}' large or
varied to prevent him from falling, I have noted one or
two which I may attempt to correct in the proper place
on a future occasion. George M. Edebohls, M.D.

New York.

THE XATIOXAL ASSOCIATIOX FOR THE
STUDY AND PREVENTION OF TUBERCU-
LOSIS.

To THE Editor op the Medical Record:
Sir: I am in receipt of a number of inquiries from all
over the United States and from abroad, concerning the
outcome of the various meetings which have taken place
in Baltimore, Philadelphia, New York, and Atlantic
City in regard to the formation of a national tuberculosis
association. Although your paper published a para-
graph concerning the Atlantic City meeting, it must have
escaped the notice of many of my correspondents.

The constitution and by-laws of an American National
Association for the Study and Prevention of Tuberculosis
were adopted on Monday, Jime 6, at Atlantic City. The
objects of the organization, as stated in its constitution,
are as follows: (a) The study of tuberculosis in all its
forms and relations; (6) the dissemination of knowledge
concerning the causes, treatment, and prevention of tuber-
culosis; (c) the encouragement of the prevention and
scientific treatment of tuberculosis.

The following arc the officers of this association : Presi-
dent, Dr. Edward L. Trudeau of Saranac Lake, N. Y.;
Vice-Presidents. Dr. William Osier of Baltimore and Dr.
Hermann M. Biggs of New York; Treasurer, Dr. George
M. Sternberg of Washington, D. C; Secretary, Dr. Henry
Barton Jacobs of Baltimore. The Board of Directors, in
addition to the officers above named, consists of Drs. Nor-
man Bridge, S. E. Sollv, John P. C. Foster, Arnold C. Klebs,
Robert H. Babcock. J. N. Hurtv, Wm. H. Welch. H. B.
Jacobs, John S. Fulton, Henrv M. Bracken, Wilham
Porter, Edward O. Otis, Vincent Y. Bowditch, Frederick
L. Hoffman, S. A. Knopf, Edward T. Devinc, Charles L.
Mmor, Charles O. Probst, Lawrence F. Flick, Mazyk
P. Ravenel, H. S. Anders, Leonard Pearson, M. M.
Smith, George E. Bushnell, and Walter Wyman.

Its membership is to consist of three classes; (a) Mem-
bers — those who are elected by the Board of Directors
and who pay annual membership dues of S5. (b) Life
members — those who pay $200 and are already members
of the association, (c) Honorary members — persons dis-
tin.cruished for original researches relating to tuberculosis,
emmcnt as physicians or as philanthropists, who have given
material aid in the study and prevention of tuberculosis.

The government of the association, the planning of
work, the arrangement for meetings and congresses,
and everything that appertains to legislation and direction,
are to be in the hands of the Board of Directors, and
committees are to have the power to execute onlv what
IS d reeled by the board. The Board of Directors is
empowered, however, to appoint an executive committee
of seven members to which is entrusted the executive
work of the association. This committee, chosen at
the meeting in Atlantic Citv, consists of Drs. Edward
L. Trxideau, Henry Barton Jacobs, Edward O. Otis. Mazvk
P. Ravenel, Arnold C. Klebs, John N. Hurty, and Mr.
Edward T. De\'ine. The Board of Directors s em-
I^owered to appoint representatives to the International
Lommittee on Tuberculosis. It was decided at the
meetrag of organization, that this representation was
to be headed by Dr. Wm. Osier, and his associates will
be selected later. The board is authorized, also to

appoint such committees as maj' be necessary for scien-
tific and educational work, and for the holding of meet-
ings and congresses.

The majority of the vast audience present at the
Atlantic City meeting were enrolled as members of the
new organization. S. A. Knopf, M.D.

16 West Ninety-fifth Street, Xew York.

THE POTASSIUM CHLORATE AND IRON
MIXTURE.

To THE Editor of the Medical Record:
Sir: Permit me to make a few remarks in connection
with Dr. W. E. Dreyfus's brief article contained on page
1043 of the Medic.\l Record of June 25. While I regret
that my name, or that of any other physician, should be
linked together with any "special" prescription — that
practice is always liable to tempt thoughtlessness and
superficial routine — I admit that the doses published by
the doctor are fairly correct. It will be noticed that a
teaspoonful contains a grain of potassium chlorate and
the double dose of the tincture of ferric chloride. When a
dose is given everj- hour the amount taken in the course
of a day amounts to about 16 or 18 grains of the salt.
That is as it should be according to my teaching of the
last forty-five years, in the case olE a child of from two to
six years of age". The same rules w^ere given in the American
Medical Times of i860, in the second volume of Gerhardt's
"Handbuch" (1876) and in my "Treatise on Diphtheria"
(1880).

From the latter, which I happen to find on my shelves,
I beg to quote what I could never sufficiently impress on
colleagues or students: (Page 160) "The local effect cannot
be obtained with occasional doses, but only by doses so
frequently repeated that the remedy is in almost constant
contact with the diseased surface. . . . It is better
that the daily quantity of twenty grains should be given
in fifty or sixty doses than in eight or ten ; that is, the
solution should be weak, and a drachm or half a drachm
of such a solution may be given every hour or everj- half
hour, or every fifteen or twenty minutes, care being taken
that no water is given soon after the remedy has been
administered for obvious reasons."

One of the main effects of the potassic chlorate is its
preservative influence on the mucous membrane of the
mouth, which should be kept as intact as possible to guard
against the spreading of the membrane. From that point
of view the recommendation to use the mixture in question
as a gargle cannot be objected to. But (i) small children
do not gargle, and (2) "gargles are not of much service"
(in diphtheria) "for the simple reason that they do not
come mto immediate contact with the affected parts, and
reach at the utmost to the anterior pillars of the soft palate"
(page 192). I cannot help being delighted with my
knowledge of the fact that this simple observation, prob-
ably not even original, and published by me first, forty-
four years ago, has often been rediscovered and has given
rise to numerous essays.

I have reason to believe that the composition as found
in many drugstores is not always equal to that which is
published by Dr. Dreyfus. The proportions given by
him are. as I said, fairly correct. His chemical expositions
are very gratifying. The individual physician will make
such changes as will suit his case or cases. Very prob-
ably the next edition of the "Bellevue Hospital Formu-
lary" will make appropriate alterations if the formula will
ever be reprinted. I never knew it formed part of the
formulary imtil lately. President Brannan was good
enough to promise a revision at the proper time.

A. J.\coBi. M.D.

Bolton Landing. Lake George, N. Y.. June 16. 1904.

The Blood in Malignant Disease. — Ernest Cunliffe. as
the result of a year of fellowship work upon the blood in
carcinoma and sarcoma, formulates the following con-
clusions: (i) There is a constant decrease in the h:emo-
globin and haemoglobin index. (2) The number of red
cells is unaffected until the disease is advanced or the
patient has suffered loss through hemorrhage. (3) Leu-
cocytosis is the rule. It is caused especially by hemor-
rhage, metastasis, ulceration, and septic infection. It
may be absent, however, throughout. Its sudden occur-
rence in such an instance indicates the probability of a
metastasis. (4) The polymorphonuclear neutrophiles
are increas*"' in number. This feature may be present
without th otal number of leucocytes being raised, and
in this relation points to the presence of malignancy. It
is therefore a diagnostic sign of importance. — Medical
Chronicle.

July 2, 1904]

MEDICAL RECORD.

prngrpsa nf Mpiiiral ^rintrr.

The Boston Medical tiijj Siirgioal Journal, June ^3, 1904.
A Case of Labor in an Epileptic. — Annie Lee Hamilton
gives the history of this interesting case. The patient
was a primipara, twenty-six years of age. She had been
subject to epileptic attacks for twelve years. She had
sometimes had as many as two or three attacks in a week.
During her pregnancy they were less frequent up to the
sixth or seventh month, then rather more frequent
between the seventh and eighth months. Up to Decem-
ber 8, four days previous to her entrance to the hospital,
she had not had a convulsion for four weeks. On Decem-
ber 8 she had three, and two or three on each ensuing day
until the eleventh, when she had five before coming to the
hospital. She was now about eight and one-half months
pregnant. She seemed to be in pain, and at first she
resisted examination. The patient had two convulsions,
and it was decided to dilate manvially and deliver. There
was no laceration. The patient soon apparently recov-
ered from the ether but did not recover consciousness.
The baby did very well for the first week but died within
a few weeks of convulsions. The patient's condition for
several days required very close watching. Finally, on
December iS. she began to improve, and in talking, kept
to the line of thought very well. On December 31 she
was sent home, in very good condition. The treatment
in the hospital was chiefly symptomatic. Elimination
was carefully looked after and the nervous symptoms were
treated by sodium bromide and hydrotherapy. Since her
return home the convulsions have been decidedly less fre-
quent. There seems to be very little in the literature in
regard to this condition.

Medical Ncu^s, June 25, 1004.

The Tracheal Traction Test as an Aid in the Recognition of
the Asthmatic Lung. — Albert Abrams concludes that; When
the head is thrown forcibly backward, the normal reso-
nance obtained by percussion over the manubrium and
lungs contiguous thereto, becomes converted into a dull or
iat sound. This nianoeuver the writer has called the
tracheal traction test. The tracheal traction test is posi-
tive in health and in all cardio-pulmonary affections, but
it is negative in cases of idiopathic asthma. The recogni-
tion of this test affords a valuable aid in the diagnosis of
idiopathic asthma, and assists in its differentiation from
symptomatic asthma and other spasmodic pulmonary
affections which suggest an asthmatic genesis. The man-
reuver specified as tracheal traction, evokes contraction of
the bronchial muscle by stimulation of the pneumogastric
nen.-e6. In asthma the tone of the bronchial muscle is so
reduced, that it no longer responds to vagus stimulation
brought about when the neck is forcibly extended on the
sternum: hence, the tracheal traction test in idiopathic
asthma is negative.

Acute Thyroidism Following Curettage. — Brooks H.
Wells reports a case of this nature. The patient, aged
fifty-three, had passed the menopause at the usual time,
but for the last six months had had repeated small bleed-
ings from the uterus which was not enlarged and was
freely movable. The patient for many years had had a
slight enlargement of the right lobe of the thyroid, slight
tremor, but no protrusion of the eyeballs. To exclude
cancer of the fundus, a curettage of the uterus was per-
formed. The scrapings showed only a moderate grade of
endome>tritis. Six hours after the operation, the patient
was flushed, tremulous, nervous and voluble, although her
mind was clear. The pulse had risen to 130, and the tem-
perature was 100.5° F. These symptoms increased in
severity, excepting the temperature which fell. The thy-
roid was enlarged, especiallj- on the right side, and pre-
sented quite an apparent thrill. There was marked
throbbing of the heart and the large arteries. Examina-
tion of the urine revealed neither albumin nor casts.
There were many colon bacilli, however, and a few piis-
cells. These symptoms of extreme toxaemia continued to
the end of the first week. On the t<-nth day the tempera-
ture reached 104.8° with a pulse of 148. There was no
leucocytosis. Death was expected at any time from the
fifteenth to the twenty-fourth day. The heart-action was
most rapid and weak when the temperature was lowest.
Diarrhoea ceased to be troublesome on the twenty-first
day. On the twenty-fourth day the patient began to
improve, and finally reached a condition approximating
that before the operation.

Iodine and Mercury to Combat Local Infections. — Aug.
Stabler describes a general method of treating local infec-
tions which has given him the most gratifying residts in
many cases of various kinds. The solution of iodine which
he applies to mucovts membranes, is as follows : A men-
stnjum is made of equal parts of glycerin and water. To
this is added tincture of iodine one drachm to the ounce, with

a little belladonna and carbolic acid as local sedatives.
This solution is applied through a simple hand atomizer
to throat and nose, or to the uterus, vagina, urethra, or
skin, in any way that is indicated. In using the atomizer,
the patient holds the tube between the teeth with lips
closed in the same position as in smoking a pipe, and
breathes through the nose. The spray will come through
the nose when the bulb is worked. Calomel is given
internally in moderate doses, frequently repeated, and so
mercuric iodide is formed in the system. In rheumatism
this treatment achieves brilliant results. If used early,
suppuration of the tonsil and joint and heart affections
rarely occurs. In acute articular, the writer applies an
iodine plaster to the affected joint. He also pushes the
mercury intemallj', and gives a little acetanilid and salol.
Subcutaneous affections, such as boils, felons, etc., are
treated with the happiest results in this same waj-. The
writer usually combines ichthyol and tincture of iodine, of
each one part, with six parts boroglyceride. This is
applied on lint or absorbent cotton, which is covered with
parchment paper and a bandage.

New York Medical Journal, June 25, it;04.

Albuminuric Retinitis. — L. Webster Fox notes that
the retinitis of Bright 's disease occurs in about 30 per
cent, of all cases of this malady, especially with the con-
tracted kidne)'. It is nearly always bilateral, but may be
tuiilateral. He describes the changes found in the acute and
chronic forms respectively and refers to the accoinpany-
ing blood changes. Vision is nearly alwaj^s impaired or
lost according to the number, extent, and situation of the
hemorrhages. Prognosis as regards life is very grave.
The treatment of the general condition will afford the best
possible chances for improving the ocvilar area. The
importance of the question of albuminuric retinitis lies
in the necessity of making an early diagnosis, and the
ability to do this is to a large extent denied the general
practitioner, unless he has been trained in the use of the
ophthalmoscope, as the symptoms, headache, and loss of
vision are common to a number of less serious affections,
and in the absence of expert advice on the subject such a
patient might go wandering about aimlessly until too late
to employ any measures which would be of any benefit
whatever.

A Plea for a Truer Therapy — Real Treatment of the
Sick. — Dr. W. C. Abbott refers to the fact that many
physicians have lost faith in drugs and constantly pre-
scribe empirically without a clear conception of what they
wish to accomplish. In regard to dosage he notes that
the effective dose depends on both the absorptive and
eliminative powers of the patient. It must therefore
constantly vary in both amount and frequency. There
being absolutely no way by which we can determine a
priori the amount of any "drug which will produce the
effect desired in any given case, it is left for us to find that
dose by giving to effect — either remedial or physiological
— beyond which we should not go. The only avenue of
escape from therapeutic nihilism lies along the road of
medication by active principles in small doses given to
effect. Not alone by deduction is this the only" rational
therapy, but clinical experience with the active principles
proves it absolutely. There can be no hesitation in
adopting the active principles, if we admit the obvious fact
that all medicinal action that a drug possesses is the
result of the presence in that drug of one or more active
principles. If of one, then does this active principle
contain in itself a full expression of the therapeutics of the
drug? If more than one active principle is present, then
is it not better and more scientific, more exact, to study
the action of each separately, than to give such empirically,
hoping to get the desired results, which perhaps depend on
the presence in excess of a certain alkaloid?

American Medicine. June 25, 1904.

Primary Typhoidal Cholecystitis, with Calculi. — Francis
S. Stewart operated on the patient, whose case he reports.
For three weeks before operation the woman, aged twen-
tv-six, was intensely jaundiced. On admission to the
hospital the temperature was 101° F., and the pulse 100.
The blood coagulated in one minute. When the distended
fundus of the gall-bladder was opened, there came out a
small quantity of clear fluid and then a large quantity of
sand and greenish-vellow pus. A stone about three-quar-
ter inch in diameter was removed from the sacculation
near the cystic duct. The pus from the gall-bladder gave
a pure culture of bacillus typhosus. After this report was
received, a test was made for the Widal reaction with pos-
iti^-e results.

The Larynx in Beginning Pulmonary Tuberculosis. — W.
G. B. Harland declares that examination of the larynx in
all cases of tuberculosis can give important information.
This may be positive or negative. In either case it will
be of use in making a prognosis, and may give valuable

MEDICAL RECORD.

[July 2, 1904

assistance in arriving at a diagnosis. Frequently, slight
changes in the larynx are observed earh' in tuberculosis
of the lungs. These changes may be congestive or anae-
mic. The writer declares that in the usual run of cases
of beginning tuberculosis of the lungs, an examination of
the larynx may give the first clue to the presence of the
lung infection. When the larynx is the chief seat of the
disease the diagnosis and prognosis must be founded on
the local appearances present. In all cases the lesions
observed in the larynx, as is true of those found elsewhere,
will be of most vakie in making a diagnosis and prognosis
when taken in connection with a thorough careful study
of the case as a whole.

Three Points of Interest Concerning Smallpox and Vac-
cination. — Bernard Ktihn reports three cases from which
several conclusions may be easily deduced. The first
patient, a girl of ten, although she had a physician's cer-
tificate of successful vaccination four or h\e years before,
developed smallpox. No scars could be fotmd on her
arms. Several days later the girl's uncle developed the
disease. He had been vaccinated several weeks before
contracting the disease. It was doubtless a case of spuri-
ous vaccination due to poor virus. No vesicle was formed.
A baby sister of the first patient, about seventeen months
old, was vaccinated by the writer eight times, separate
tubes of virus being used, the virus being very potent.
None of them took, neither did the child contract small-
pox, although she had countless opportvmities for doing so.
Tliis must have been a rare case of natural immunity to
smallpox and vaccinia also. The manufacture of vaccine
virus should be more carefully supervised by the govern-
ment. And more care should be exercised in the issmng
of_ vaccination certificates and in admitting children to
sc'nool on the strength of them.

The Lancet, June 18, 1904.

On the Etiology of Scurvy. — M. Coplans gives an exten-
sive review of his personal experience with scurvy in the
Transvaal and Orange River Colonies during the Boer war.
lie concludes that the disease is not due either to the pres-
ence or absence of any particular kind of food from the
dietarj' but rather to an infection for which the food may
act as a vehicle under conditions of impure storage or
impure preparation. In his experience the disease pre-
vailed in inverse proportion to the personal standard of
hygiene, and this would seem to indicate that its infectivity
depended on the insanitary habits and possibly the
unwholesome occupations of those who were stricken with
it.

Lymphatics of the Larynx and Malignant Disease. — P.

d<> Santi discusses the anatomy of the laryngeal lymph
channels and believes that these anatomical considerations
have a direct bearing on the matters of choice of operation
and prognosis. .-Xs regards the former the question turns
on (i) the site of the origin of the disease and (2) the stage
in which diagnosis is made. If an epithelioma of strictly
intrinsic origin is seen and diagnosticated early while it is
still limited, thyrotomy is amply sufficient to eradicate the
disease. Jn the absence of obvious glandular involvement
experience has shown that there is no need to perform a
set operation to remove the group of glands liable to infec-
tion. On the other hand in most advanced cases of intrin-
sic cancer which necessitate removal of one-half of the
larynx the corresponding glands ought to be removed
whether they seem enlarged or not.

The Treatment of Tabes Dorsalis and Its Prognosis. — ■
Maurice Faure notes that while certain cases of syphilitic
tabe. improve rapidly under vigorous mercurial treatment
it is certain (i) that no tabetic gets well solely on account
of the quantity of iodide or of mercury whicli he absorbs,
and (2) that aggravation of the disease is more frequent
among tabetics who are put on an antisyphilitic treatment
in increasing doses than among those who are not treated
in this way. It is necessary to avoid attributing exclus-
ively to the action of heroic remedies, such as mercury, the
relaxations and the diminutions in the symptoms of dis-
ease which are sometimes obser\-ed in the majority of cases
of tabes, for such ameliorations are the rule, and it is incor-
rect to say that locomotor ataxia must be a disease which
is necessarily and invariably progressive. The disease is
steadily progressive in a third of the cases. It is arrested,
improved, or gets well in about a fourth of the cases and
in the remainder it proceeds very slowly with periods of
quiescence only affecting the life of the' patient seriously
on occasions, and during the rest of his life offering him
the possibility of living a life the activity of which doubt-
less must be diminished, but which is by no means very
uncomfortable. .\s regards treatment, the best results will
follow from care of the bladder, keeping the bowels open,
attending to nutrition, pro\-iding against insomnia, com-
pelling open-air life, preventing overwork, mental or phys-
ical, and by attending to the circulatory system.

British Medical Journal, June 18, 1904.

Appendicular Colic. — W Hesketh Evans describes one
of his own cases in which, from time to time, appendicular
colic was severe. There was no rise in temperature or
alteration in pulse, but the pain became so severe that
operation was performed. On cutting open the excised
appendix, a dark-brown, semi-solid, foul-smelling sub-
stance oozed out. In the interior were several small pock-
ets containing a similar substance with fecal odor. Large
doses of opium would have probably masked the only
symptom, and the termination might then have been fatal.

A Case of Leukanaemia. — F. Parkes Weber reports this
case and sums up the main features as follows: Progres-
sive wa.xy pallor and asthenia v.^ith maintenance of sub-
cutaneous fat; changes in the red-blood corpuscles rather
similar to, but not so extreme as, those met with in true
pernicious anemia; absence of true leukaemic changes in
the blood, but presence of slight myelocythsemia and pres-
ence of the in\-erted proportion of lymphocytes to poly-
morphonuclears, which is found in cases of lymphatic pseu-
doleuka?mia ; no abnormal amount of pigment in the urine ;
changes found after death in the haemopoietic tissues, simi-
lar to those which occur in cases of "mixed-cell " leuksemia,
or pseudoleuk;cmia; abnormally firm consistence and
increase of connective tissue in the bone-marrow from the
shaft of a long bone; absence of enlargement of the ordi-
nary lymph glands, but great hyperplasia of the spleen
(haemal gland) and prevertebral haemolymph glands:
absence of any reaction in sections of the spleen, liver,
and kidneys for free iron, such as is found in pernicious
anaemia. Charcot-Leyden crystals were not noticed in
the bone-marrow, etc., but were not specially looked for.
In spite of the poikilocytosis, the writer believes the dis-
ease in the present case to have been primary in the bone-
marrow

The Deterioration of Vision During School Life. — Ettie
Saycr h.as made a careful stud«r of this subject. She has
discovered that, at six years of age, 3 percent, of school
children ha\-e seriously bad vision, and 8S per- cent, can
see 6-6 with each eye. At eleven years of age, 11 per
cent, have seriously bad vision, and only 58 per cent, see
6-6 with each eye. The rest have slight defects. The
writer declares that no child's eyes were intended by nature
to undergo the strain of accommodation for lessons, for
six or seven hours every day of their lives, between four and
fourteen years of age. But if compulsory education enforces
it it becomes the duty of the Board of Education annuallj-,
to separate those 20,000 children or more, whose vision is
so defective that they are unfit physically, to devise for
them a specially modified curriculum, and to provide them
with glasses if their parents are too poor or too ignorant,
to do so. There is plenty of skilled manual work to be
done by the class which is so poor that the public has to
pay for their education, and they should be taught from
their earliest infancy to regard this as their special lot in
life. Not only the child with defecti\e vision suffers, but
also future generations. All eyes should be tested imme-
diately on the child beginning its education, as to \-isuaI
acuity; as to rapidity of perception; as to color blindness.
.\tno time during school life should type smaller than pica
be used. While infants should be allowed to use only
chalk on cardboard. Reading should be learned from the
blackboard. There is no defect more Hkely to be trans-
mitted from parent to child, than that of defective eye-
sight.

Deutsche medisinische Wochenschrift, June 9, 1904.

Tuberculous Pericarditis. — Scagliosi reports an instance
of this rare condition as occurring once in 1077 autopsies
made at the University of Palermo. The patient was a
woman of sixty who died as the result of a pyelonephritis.
.'\t the autopsy a moderate amount of serous fluid was
found in the pericardium, and the inner layer was ir-
regularly covered with small nodules, which were later on
determined to be tuberculous. The lesion was proved to be
primary in the pericardium, and the author thinlcs that the
patient's age was the .predisposing factor in determining
this localization. It is well knowm that the blood-vessels of
the heart in older persons are usually more or less diseased,
and thus offer a point of lessened resistance. Careful
histological examination of all the other organs and the
lymphatic glands failed to reveal any traces of tuberculous
processes. It seems rational to assume, therefore, that a
primary tuberculous pericarditis may exist as a disease
entity.

Rupture of a Tuberculous Abseess into the Trachea. —
Gaudiani directs attention to the possibility ot a destruc-
tion of the walls of the air passages by the softening of
masses of tuberculous cervical lymph-nodes. This may be
followed by a sudden invasion of the trachea and the
bronchi, leading to death by asphyxiation. .An instance of
this comparatively rare condition is reported as having

July 2, 1904]

MEDICAL RECORD.

occurred in a child of three, who had just recovered from
what was supposed to be an angina. A few days later,
sudden dyspnoea came on, and although a tracheotomy
was done it was iinpossible to save the child. Autopsy
showed that the trachea down to the bifurcation was
surrounded by a mass of glands. A perforation had taken
place and the bronchi were filled with cheesy masses.
This case also shows the difficulties attending the proper
diagnosis. The only differential point which distinguishes
this from laryngeal stenosis is the character of this voice,
which is but slightly affected in the former condition.
No other symptoms may have been present to point to the
extensive character of the diseased processes in the glands.

Treatment of Injuries to the Diaphragm. — Rona calls
attention to the seriousness of this class of injuries, in
which the proper surgical treatment is an urgent necessity.
The patient, a boy of fifteen, presented a stab wound of the
chest between the eighth and ninth ribs, through which a
considerable portion of omentum protruded, pointing to
an injury of both the pleura and the diaphragm. The
transthoracic method of operation was employed, and
after exposing the eighth rib under Schleich anssthesia, a
portion about 15 cm. long was resected. This disclosed a
slit in the diaphragm about 4 cm. long, through which
the omentum protruded. The latter was cut way after
ligature and the stump dropped back into the abdomen.
The upper border of the womid in the diaphragm was then
sutured to the parietal peritoneum and the skin wotmd
closed with the exception of the lower angle, in which a
few strips of gauze were introduced for drainage. The
patient made an uninterrupted recovery.

A New Property of the Tubercle Bacillus. — Piatkowski
presents a preliminary communication dealing with the
difTerentiation of the tubercle and the other acid-resisting
bacilli. His method is based on the observation that the
acid-resisting bacteria may be isolated from a mixture
by diluting a small quantity of the latter with water or
bouillon (10 c.c.) and then adding two to three drops of
formalin. This is thoroughly shaken in a test-tube, and
after half an hoiir a culture is made in a plain agar, or a
glycerin-agar tube. Successive cultures are made from
the same mixture at intervals of about fifteen minutes.
In one or more of these tubes a pure culture of the bacillus
vnll be found. It appears that the group of acid-resisting
bacilli is less sensitive to the action of the diluted formalin
solution than other varieties of bacteria. But even these
are killed after prolonged exposure to the formalin, and so
the difference is one of time only. The formalin solution
has no effect whatever on the morphological character-
istics of the acid-resisting bacilB and does not affect their
staining properties. The author considers that this
method can be more simplified, and is making further
researches in this direction.

Berliner klinische M'oehcnsehrift, June 9, 1904.

Gonorrhceal Phlebitis. — Heller reports an instance of this
rather rare complication of gonorrhoea, a search of the
literature disclosing the fact that this is only the twentj'-
sixth case on record. The patient presented neither
varicose veins nor any other factor which could be con-
sidered as an etiological factor. About fotir weeks after
a gonorrhoea, which had apparently subsided, he developed
a marked phlebitis of the lesser saphenous veins and the
pampiniform plexus, which gradually disappeared under
appropriate treatment. The affection seems to be foimd
most often in young men between the ages of twenty and
thirty, and tisually comes on during the first attack of
gonorrhoea, during the subacute stage. An arthritis was
present in most of the cases reported. A varicose condi-
tion of the veins was noted in but one instance, so that this
cannot be looked upon as a predisposing factor. The
veins of the lower extremity are involved in the large
majority of cases, particularly the saphenous vein. The
principal symptoms are pain and localized oedema, and the
average duration of the disease is about six weeks. The
prognosis is usually good, although a few fatal cases have
been reported. The author considers that the process
may be due to the rupture of some hidden focus, most
likely prostatic, and the entrance of the septic material
into the venous circulation. Treatment is that of
phlebitis elsewhere.

Fatty Degeneration. — Rosenfeld thinks that this term
should be limited to that condition in which an organ con-
tains more fatty tissue than is normally present. This
must be determined by chemical or microscopical methods.
The latter, however, seems inadequate in most instances to
afford any reliable quantitive estimate of the fat present in
anv given organ. Of the chemical methods, that which is
based on the extraction by alcohol or chloroform seems
most efficient. The author attempted to ascertain by
experiments in animals which organs are the most liable to
undergo a fatty degeneration. These were given phos-

phorus, phloridzin, chloroform, alcohol, and various other
materials. The liver was apparently the most quickly
affected. As regards the heart, chloroform and canthar-
ides had no effect, alcohol and potassium bichromate
caused an increase of about 2 per cent., phosphorus and
phloridzin about 4 per cent., and extirpation of the pan-
creas was followed by an increase of 6 per cent. It seems,
therefore, that there is no connection between the two in
cases in which a patient dies from poisoning by chloroform
and a fatty heart is found at autopsy. In the kidney a
marked decrease in the amoimt of fat present is produced
by cantharides and chloroform, very little change follows
the administration of either phosphorus or potassium
bichromate or extirpation of the pancreas, but a rather
marked increase in the amount of fat is produced by
alcohol. Muscular tissue, as a general thing, afforded the
surprising picture of a diminution of the fatty elements
rather than an increase. The author concludes from his
observations that in those organs where fatty degenera-
tion is present the fat arrives there by a process of
migration.

M unchener medizinische Wochenschrijt, June 7, 1904.

Treatment of Skin Diseases with the X-rays. — M tiller
reports on the employment of this agent in pruritus,
hyperidrosis. and chronic eczema. By the use of mode-
rately soft or even very soft tubes he obtained excellent
results, but does not consider it wise to apply the method
indiscriminately in these diseases without having tried
other procedures. A case of pruritus vuU-ae of long
standing which had resisted other treatment was entirely
cured after five exposures. In the case of profuse sweat-
ing of the hands, the exposures were followed by an ex-
foliation of the skin, and from the new dermal covering
this excessive perspiration was absent. Another patient
with this condition in the anal region was also favorably
affected. The cases of chronic eczema were freed from
the itching and the indurated skin after a few exposures.

Value of Lumbar Puncture in Meningitis. — Wertheimer
believes that Quincke's method of lumbar puncture
affords the means of offering a better prognosis in many cases
of meningitis in children, especially in those instances in
which this disease follows a pneumonia or acute infectious
process, and in which the meningitis may with considerable
certainty be considered of the serous type and free from
bacteria' He claims that the therapeutic value is also
considerable and believes that partial evacuation of the
cerebrospinal canal should not be delayed until the test
puncture has shown the presence of a "high intracranial
pressure. Rather it should be done as soon as the general
symptoms, particularly the condition of the eyes, point to
an increased cerebral pressure, and then the puncturing
may be kept up imtil the pressure disappears. The
author reports a case in wTiich a meningitis followed a
pneumonia, in which 560 c.c. of fluid werere moved from
the spinal canal at intervals of several days. The fluid
was proved free from bacteria. The symptoms subsided
and the child made a good recovery.

French and Italian Journals.

A Case of Total Hysterical Deafness. — Bouyer has had
imder his care a case of total hysterical deafness which
developed suddenly in consequence of a violent emotion.
There is complete "suppression of perception both by the
medium of air and bone. The deafness has several tmies
been momentarily suspended imder the influence of certam
therapeutic measures, which appeared to play especially
a suggestive role — insuflilation and electric treatment.
The patient was able to preserve for several moments a
normal perception, but soon the somids became confused,
and were lost in a distant murmur, which signalled the
progressive rettim of the auditory nerve to numbness,
and the development of intellectual torpor. — Gazette
Hebdomadaire des Sciences Mcdicales. May 29, 1904

Intestinal Occlusion by an Enormous Uterine Fibroma;
Entire Relief of the Symptoms by Means of Right Lateral
Decubitus. — Paul Gallois reports this case of a woman
forty years of age, suffering from an enormous uterine
fibroma. Constipation was persistent, the abdomen ^yas
distended, and the patient suffered from fever. Vomitmg
was also a troublesome symptom. The patient could not
eat, and grew cachectic. The condition was growmg
alarming. It occurred to the writer to advise the patient
to lie on her right side. He reasoned that this position
would disengage the sigmoid flexure, and besides, it would
throw the weight of the tumor on to the distended in-
testinal loops and increase their power of evacuation.
Soon after the patient was able to lie on her right side
gas escaped from the intestine, and fsces were quickly
passed. — Le Bulletin Medical, May 28, 1904.

Hysterical Polydipsia and Polyuria of Eleven Years'
Duration. — Sollier has observed a case of polydipsia and

3°

MEDICA-L RECORD.

[July

1904

polyuria in a young woman who drank from 12 to 17
litres of water "daily with no complication of alcoholism.
The polydipsia had" been cattsed by a sensation of burning
in the cesophagus, the effect of an acute hysterical attack
which developed at the age of seventeen years. The
burning sensation was relieved by drinking cold water.
The polyuria, resulting from the polydipsia, persisted for
eleven consecutive years, and then ceased, when the
hysterical troubles were relieved. The patient was treated
in a sanatorium by measures generally einployed in
hysteria — isolation, rest in bed, and mechanotherapy.
Within three months, a complete cure resulted without the
aid of any hypnotic suggestion of any kind. — La Presse
Midicale. May 28, 1904.

A Large Foreign Body in the Nasal Fossae .^Texier
reports this unusual case of a man without morbid ante-
cedents who was suffering with a suborbital fistula. There
was a mucopurulent discharge from the nose. The fistula
was thought to be due to a fall which had resulted in an
abscess of the cheek. Two years before the patient's
arm had been amputated as a result of injury by the ex-
plosion of a firearm. On examining the fistula, it was
found that a probe could be pushed inward and back-
ward for 12 cm. Rhinoscopic examination showed the
presence of a foreign body which had gone through the
septum, penetrating both nasal fossae. It proved possible
to seize the object through the fistula orifice and extract
it. It was found to be a piece of iron about the size and
length of the little finger. It had penetrated the nose at
the time of the explosion, but the injury of the arm had
been so severe that the accident to the nose had passed
unnoticed. — La Bulletin Medical, May 18, 1904.

Results of Some New Researches on the Etiology of
Rabies. — A. Negri states that in the nervous system of
animals affecteci with hydrophobia is found a micro-
organism of the nature of a protozoon. It is found in the
cells of the cerebrospinal axis. In dogs which have died
of rabies furiosa after subdural injections of the virus,
they are found in the encephalon, especially in the cornu
ammonis. They are round,, oval, or angular, when of large
size. Many are smaller and round. They vary in size
from I to 20 /U in diameter. The smaller ones are homo-
geneous, the large ones granular, irregular in shape,
nucleated, with one or more nuclei. They may invade all
the cells of the nervous system, the cells of Purkinj^, the
cerebral cortex, pons, medulla, and Gasserian ganglion.
In rabies paralvtica the distribution is different; when
inoculated in the sciatic, the disease is ascending, and
attacks the cells' of the spinal ganglia, and is not found in
the brain. The author has found this organism in one case
in man. They are soon destroyed by caustic alkali, but
are not injured by acids. Drying, heat, putrefaction,
glycerin, water, and physiological solutions do not affect
their virulence. — Lo Sperimeiitale, April, 1904.

Movable Kidney and Enteroptosis. — H. S^r^g^ calls
attention to the frequent coincidence of enteroptosis with
the movable kidney. The latter condition is, in the great
majority of cases, to be considered as one of the phenomena
in the general process of splanchnoptosis. Gastro-
intestinal troubles in general, particularly those of infancy
and adolescence, handing down a defective state of
nutrition, are the origin of the process of ptosis in 54 per
cent, of the cases. Pregnancy, alone, without other
antecedent morbid cause, followed by serious dyspeptic
troubles, appears to be the first cause in the proportion of
32 to 100. Multiplicity of pregnancies does not seem to
augment the trouble to any sensible degree. Periodic
congestion is noted as a cause. Traumatism is a rare
cause. The treatment of the movable kidney, the writer
believes to be essentially medical. As to surgical treat-
ment, it should never be attempted till medical treatment
has failed. The writer calls attention to the importance
of the Gl^nard supporter. Besides this, he advocates the
use of daily laxatives, the meat regime, and the use of
alkalines. His results have been most encouraging. He
believes in the use of the supporter even in cases in which
the abdomen is not prominent. — Journal dc Medecine de
Bordeaux, May 29, 1904.

Four Conservative Csesarean Sections and One Destruc-
tive One for Osteomalacia. — T. Morisani publishes five
cases of cajsarcan section done for pelvic deformities,
three rachitic, two osteomalacic. The children were all
saved. One mother died of sepsis. In one the uterus
was removed, while in the others it was left. The author
advocates making an incision in the median line of the
fundus, from the highest portion, extending as far toward
the symphysis as is necessary. The incision should avoid
the location of the placenta as far as it can be ascertained,
as this lessens the danger from hemorrhage. Hemorrhage
depends less on the cutting of large vessels than on a lack
of uterine contraction. In the median line of the uterus
there are few large vessels to be cut. The extraction is

also easier, and there is less danger of rupture of the
uterus in a subsequent pregnancy because the scar is
firmer. The higher up the incision, the stronger is the
uterine muscle cut through. There is also less danger of
ventral hernia, since the incision does not reach near the
symphj'sis. — Archivio di Ostetrica e Ginecologia, March,
190 |.

Comparison of the Agglutination of Different Tuber-
cle Bacilli, in Relation to the Origin of the Bacilli
and of the Serimis. — M. S. Arloing and Paul Courmont
conclude that: fi) Certain homogeneous cultures of
tuberculosis are not agglutinable by tuberculous serums,
even by serums obtained by inoculation of this same
culture. The origin of the cultures does not seem to be
the cause of the failure of agglutinability. They can-
not serve for serum diagnosis. 2) The homogeneous
cultures which are agglutinable, are so. whatever be their
origin, in contrast to all the tuberculous agglutinating
serums. The writers do not refer to the degree of ag-
glutinating power. (3) Reciprocally, the experimental
tuberculous serums, whatever may be the origin (human,
bovine, or avian) of the infecting tuberculosis, are
agglutinating for all the specimens of agglutinable tuber-
culosis. (4) Practically, the cultures of human tuber-
culosis are agglutinated by the serums of bovine tuber-
culosis and the cultures of bovine tuberculosis bj' the
serums of human tuberculosis. The method of serum-
diagnosis is then applicable to all kinds of tuberculosis,
of whatever origin, on the condition of having a culture
that is very agglutinable. (6) The study of -agglutina-
tion does not allow of establishing very sensible differences
between tuberculoses of different origin, especially be-
tween human and bovine tuberculosis. — Lyon Medical,
April 24, 1904.

The Pathological Anatomy of Acute Delirium. — U-
Alessi publishes the account of a case of acute delirium,
with pathological findings and some observations on the
case. The patient, a man of thirty-five years, was of
peaceful character, and had never indulged to excess in
alcohol or tobacco. The onset of the disease was sudden,
with acute mania of riches: he became loqviacious. ir-
ritable and incoherent, unable to recognize his friends.
This increased to excitement, motor irritability, insomnia,
refusal of food, and a fever of 37° to 42°. This condition
went on to extreme debility, coma, and death. A culture
made from the blood showed the presence of pure cultures of
pyogenes communis, which was also found in the brain.
Examination of the cells of the brain showed marked
degeneration of the cells, an acute parenchymatous
degeneration of the fundamental nervous elements, i.e.
an encephalitis. The author thinks that the title used for
such affections should be based on the pathological con-
ditions found, rather than on the cUnical symptoms.
Hence such a case should be called an acute parenchyma-
tous encephalitis, rather than one of acute delirium. The
cause of such an encephalitis may be a variety of organisms,
as the bacillus of Bianchi-Piccinino, of Fraenkel. a
streptococcus infection, or one due to pyogenes com-
munis. — La Riforma Medica. April 27, 1904.

Rays and Emanations. — P. Schivardi compares the rays
derived from the Crookes' tube and those of radium. He
says that radium gives forth three sorts of rays: alpha,
with slight power of penetration, arrested by aluminium;
beta, with strong penetrating power, passing through lead;
gamma, identical with the x-raj'. A radium salt produces
heat andjlight. Radium gives out positive, negative and
s:-rays, like the Crookes' tube, but spontaneously, and not
as a result of outside stimulation. It seems to emit a sort
of gas, as it were, which attaches itself to various bodies,
and gives them radio-active powers; these are the emana-
tions of radium. Another kind of rays come from the
Crookes' tube called the n-rays, which are invisible,
obscure, and yet traverse wood, metals, and the human
body. They do not pass through lead or pure water.
They do not act on the photographic plate, but they in-
crease the luminosity of phosphoresent bodies, and make
the light of a lamp more brilliant. They also increase the
sensibility of the retina. These w-rays are a vibratory
phenomenon of the ether, while the radium emanations are
a liberation of a small amount of electricity, expelled from
atoms of radio-active substances. A phosphorescent body
is increased in brilliancy in the presence of muscular
activity, in the neighborhood of the nerve trunks, or the
central nervous system. There is a small instrument
based on this principle, by which the course of the motor
nerves can be followed out. This consists of a simple
phosphorescent carbon disk. By means of it the topog-
raphy of the central nervous system may be mapped out,
as well as the psychomotor areas in the cerebral cortex,
and the language centers. The human body also emits
n-rays, increased in power by the functioning of the body.
These emanations may serve to explain the phenomena of

lulv

1904]

MEDICAL RECORD.

telepathy and thought transference. Griffiths found radio-
activity in the petals of odoriferous plants, such as the
geranium. If a test instrument be placed over the speech
center in the cortex, speaking will cause it to become
luminous, especially in the presence of a low voice, while
when silence supervenes the instrument becomes dark. —
Gazzetia Medica di Roma, May i, 1904.

Annals of Surgery, May, 1904.
Stricture of the CEsophagus Due to Typhoid Ulceration. —

J. E. Thompson reports three personal cases and has found
nine others on record, a r&um6 of which is given: Case r
was somewhat relieved by dilatation measures, but tinally
died from inability to swallow. A similar treatment pro-
duced permanent relief in cases 2 and 3. As to the exact
nature of oesophageal ulceration in typhoid, we have no
definite information. Louis considered them as due not
to typhoid infection but rather as a complication due to
the extreme malnutrition of the tissues. It is very prob-
able that the ulcers at the lower end of the giillet are due
to peptic digestion of the oesophageal mucosa. The
ulcers have been observed in many cases of exhausting and
long-continued sicknesses. It is noteworthy that out of
the twelve recorded cases, eleven occurred in males.

Rhinophyma. — W. W. Keen describes one case of
rhinophyma resulting from an acne rosacea. In operating
he excised the central portion of the growth from the upper
margin of the diseased area down to the tip of the nose by
an elliptical incision, the long axis of which corresponded
to the bridge of the nose. H then sutured the edges. The
pressure of the finger in suturing the lobules of tissue
squeezed out from the ducts of the sebaceous glands a num-
ber of columns of sebaceous matter, commonly known as
"worms. " On the alae of the nose, as it was impossible to
obtain a suitable ellipse, he contented himself by simply
shaving off all the hypertrophied tissue The hemorrhage
was not severe; not a single vessel had to be ligated. A
few clamps applied for a few minutes and the sutures
checked the hemorrhage almost entirely, and a little
adrenalin solution applied on the raw surface where he had
shaved it completed the haemostasis. Between the dressing
and skin a bit of gutta-percha tissue was placed, so as to
prevent adhesion of the dressing to the wound, which
would retard the cicatrization. Recovery was rapid and
complete.

Postoperative Pneumonia with Experiments upon Its
Pathogeny. — The conclusions of W. L. Chapman are as
follows: (i) Prophylaxis. Care in ether giving lessens
shock and respiratory irritation, which reach their maxi-
mum when an unnecessarily large amount of ether is given.
(2) The disinfection of the mouth and oropharynx by
peroxide before operation is a rational precaution. (3)
Adecjuate air space is of even greater importance in
surgical wards than in medical. (4) A careful ausculta-
tion and percussion of the chest should precede every
operation, and if there be signs of disease, operations of
election should be postponed until the chest condition is
more favorable. (5) A complete clinical record of all
cases of postoperative pneumonia, together with a record
of the previous state of the patient, is most desirable, and
such records will in time greatly enrich our incomplete
knowledge of the factors which predispose to the com-
plication. (6) It is possible to demonstrate experi-
mentally the lesions produced by suffocation and etheriza-
tion, and the same philosophy which explains post-
operative pneumonitis may be applied to that which occa-
sionally follows poisoning by carbon monoxide and illumi-
nating gas.

Lymphatic Constitution; Care of the Lymphatics During
and After Surgical Operations. — F. Gwyer reminds us that
infection is most commonly carried through the lymphatics,
but that ordinarily the only care we take is to cut cleanly
and not tear the tissues. We should exercise the same
care in closing all lymphatic vessels and spaces as we do in
occluding the blood-vessels. In operating on diseased
glands he advises dissection to the point of exit of the
vessel, which he then ligates as he would an artery or a
vein. An additional value in his experience has arisen
from the fact that the arterial supply enters at about the
same point as the emergence of the lymphatic, and there
has been less hemorrhage than otherwise. Ligation also
facilitated the work, in that the vessels, lying usually to-
ward the bottom of the wound, dissection is more dififi-
cult, and if bleeding occurs, it is more difficult to control;
but if dissection is carried to that point and a ligature is
thrown about the pedicle, as it were, much time is saved.
In order to close up lymph spaces he rubs over the ex-
posed area sterilized vaselin or iodoform-lanoline. In
case of ordinary abscesses he incises, washes out the cavity,
swabs it dry, and then fills it with one of the above prepara-
tions. The same plan is followed in the after-treatment
of infected cases The ointment should be a soluble one.

Hence bismuth, zinc oxide, and similar preparations are in-
admissible.

Skin-grafting Infected Areas. — By "infected areas''
S. F. Wilcox refers to raw surfaces which niay or may not
ha\-e been originally aseptic but which have become
infected and from which pus exudes. To successfully
skin-graft such areas we must first render them aseptic.
The author thus describes his plan of doing this. The
night before the operation the ulcerating and surround-
ing area should be cleansed as thoroughly as possible
with green soap and hydrogen peroxide to remove the
dried crusts and debris from the granulations. In case of
very foul varicose ulcers, more time maj- be taken, and a
compress wet with 50 per cent, solution of peroxide may
be applied for a few days until the exudate is removed.
After cleansing, the raw surface is covered with a com-
press saturated with a i per cent, solution of formalde-
hyde (the or inary 40 per cent, pharmaceutical prep-
aration being the unit), and this compress is allowed to
remain in place until the patient is on the operating table.
When the compress is removed, it will be found that the
granulation layer is dry and dark red in color, having an
appearance much like smoked beef. This layer is about
a quarter of an inch in depth; it is friable, ani can easily
be scraped off with a sharp spoon from the underlying
tissue, which is whitish and bleeds very little. The re-
moval of the granulation layer should be thorough, and
what little oozing there is can be easily be stopped by the
application of the Esmarch solid rubber band for a few
minutes. The use of the rubber is a valuable step in the
operation, as the smooth rubber makes equable compres-
sion and does not stick to the tissues when removed, but
leaves an ideal surface for skin-grafting. The remainder
of the operation is the ordinary one for the application
of Thiersch's grafts. The after-treatment is the same.

Sialolithiasis. — According to O. T. Roberg, there are a
few over two himdred cases of this condition on record.
He describes one case occurring in a man of fifty-eight
years who presented a condition leading to the diagnosis
of calculus in Wharton's duct and probably in the sub-
maxillary gland with suppuration of the latter and with
suppurative cellulitis of the neck. An incision was made
under local anjesthesia into the mass, and a small amount
of thick, curdy pus escaped. One week later the swelling
was considerally smaller and pus had ceased to discharge.
The patient was then anesthetized. The nodule in the
mouth was incised, and by means of a small curette a
concretion the size of a split pea was removed. An in-
cision about three inches long was then made extemalh",
parallel with the lower border of the jaw, and one-half inch
below it. By means of blunt dissection through a mass
of dense scar tissue the submaxillary gland was exposed
and removed. The wound was packed with iodoform
gauze, and only partly closed. A second calculus was
found lodged in the beginning of the duct. Five weeks
after the operation the wound was completely closed.
After the operation there was paresis of the angle of the
mouth, from which the patient had completely recovered
four months later. Concerning the relation of bacteria to
the formation of salivary calculi, the author believes that
they cause a precipitation of the calcium salts by in-
creasing the alkalinity of the saliva and removing the
carbon dioxide. This explanation, however, does not
accftunt for the fact that calculi are found far more fre-
quently in the submaxillary gland and duct than else-
where.

Haemoptysis. — In the treatment of hjemoptysis, Dr. W.
von Bozoky does not approve of too much energy in this
direction. The patient should be laid down with neck and
chest freed from the pressure of clothing, and the upper
portion of the body raised in order to facilitate expectora-
tion. Then the patient should take deep breaths, which
tend to restrain hemorrhage by inducing coagulation of
blood and thrombus formation. Coughing should be
checked, in order that the formation or development of a
thrombus may be, as far as possible, promoted. Only a
few slight coughs may be permitted, in order to get rid of
the blood present in the upper air-passages. A morphine
injection may be gfiven with the view of calming the pa-
tient. The ice-bag may also have a favorable psychical
influence. Ergot is not of much use; it tends to raise
blood-pressure, and is not likely to be of avail in haemo-
ptysis. He does not approve of injections of gentian,
which do not seem to have a favorable influence and are
also attended by the risk of tetanus. — Zeitschrift fur
Tuberkulose und Heilstditenwesen.

MEDICAL RECORD.

[July 2, 1904

The Gazette Pocket Speller and Defi.ver. English
and Medical. Second Edition. New York: The Ga-
zette Publishing Co., 1904.
This tiny volume of 216 pages is so compactly arranged
that it can easily be slipped into any pocket. It is unusu-
ally comprehensive for its size. The words in the English
section are briefly defined, mainly by synonyms. In the
revision of this little volume nearly 700 English and more
than 300 medical words have been added without increas-
ing the size or number of pages. It is an extremely con-
venient little manual.

Obstetrics for Nurses. By Joseph B. De Lee, M.D.,
Professor of Obstetrics, Northwestern University iledi-
cal School; Obstetrician to Mercy, Wesley, Provident,
Cook County, and Chicago Lying-in Hospitals; Lec-
turer in the Nurses' Training Schools of same. Fully
illustrated. Philadelphia, New York, London: W. B.
Saunders & Company, 1904.
Although this book is'intendcd by the author to be pri-
marily for nurses, it is nevertheless, full of material valuable
to the medical student, who frequently finds in his early
years of obstetric practice the work of a nurse devolving
upon him. Two main subjects are considered — obstetrics
for nurses and the actual obstetric nursing. But the author
has so skilfully combined them that the relations of one to
the other are natural and helpful. This whole subject is
one of such vital importance that a book of this kind, em-
bodying as it does the experience of eight years of lectur-
ing to the nurses of four different training schools, is most
welcome to all those interested in obstetrics, whether nurses
or physicians. The text is divided into three parts:
Anatomy and Physiologv of the Reproductive System,
Nursing During Labor and in the Puerperium, and The
Pathology of Pregnancy, Labor, and the Puerperium.
There is an appendix treating of Visiting Nursing in Obstet-
ric Practice, Hospital vs. Home Nursing. The Obstetric
Nurse and Dietary. An excellent glossarv and an index
are appended. The illustrations, which are plentiful, are
nearly all original, and were made expressly for this book.
The author has taken the photographs from actual scenes,
so that the details are true to life. We can warmly recom-
mend this work.

Maladies des Pays Chauds. Manuel dc Pathologic Exo-
tique. Par Patrick Manson. Traduit de f Anglais
par Maurice Guibaud, MMecin de la Marine, jean
Brengues, M^dccin del'Arm^e Coloniale, et Augment^ de
Notes et d'un Appendice par M. Guibaud. Avec 114
illustrations et 2 planches en couleurs. Paris: C.
Naud, 1904.
The interest in tropical diseases has assumed such im-
portance of recent years that a contribution to the subject
like this comprehensive work now translated into the
French language, is a most welcome addition to this
branch of literature. In the introduction the author con-
siders the etiology- of tropical diseases. The book is di-
vided into seven sections. In the first, various fevers are
considered — malaria, yellow fever, bubonic plague dengue,
Mediterranean fever, tropical typhoid, tvpho-malaria,
stmstroke, unclassified fevers, etc. The second section
treats of beriberi, epidemic dropsv, and the sleeping sick-
ness. Then follow the abdominal affections — cholera,
dysentery, diarrhoea, liver abscess, infantile biliarj' cirrho-
sis, etc. Leprosy, ulcerating granuloma of the genitals,
and Oriental bubo are then discussed. Diseases due to
animal parasites and associated maladies are accorded
considerable space, and include such affections as Ivmphan-
gitis. lymph scrotum, elephantiasis, bilharzia hsematobia,
endemic hematuria, craw-craw, trichoccphalus dispar,
ascarislumbricoidcs,ankylostomumduodenale,strongvlus,
subiilis, taenia and nana', and bothriocephalus mansoni.
The section on cutaneous diseases is divided into four
parts, non-specific diseases, diseases due to bacteria, those
due to vegetable parasites and those caused by animals.
The last chapter deals with local maladies of an undeter-
mmed nature. One hundred and fourteen illustrations
are scattered throughout the text. There are, besides,
two colored plates.

A Manual op Hygiene and Sanitation. Bv Seneca D.
Egbert, A.M., M.D., Professor of Hv.eieneand Dean of
the Medico-Chirurgical College of Philadelphia; Mem-
ber of the Academy of Natural Sciences of Philadelphia ;
Mcrnber of the American Medical Association. Third
edition, enlarged and thoroughlv revised. Illus-
trated with 86 engravings. Philadelphia and New
iork: Lea Brothers & Co.. 1904.
The third edition of this valuable book will receive a warm
welcome from the many classes to whom it appeals. The
treatment of the subject is so scientific and systematic
that the book fills a want not well met bv many other
volumes on these topics. Since its appearance, five years
ago, the text has increased bv more than one-third of its

original vol'.ime. The atjthor has shown in the introduc-
tory' chapters what practical hygiene and the employment
of comparatively recent discoveries in this field are doing
for the improvement of this country, the data being de-
rived from the Reports of the United States Census of 1900.
The writer calls attention to the fact that improvement of
sanitary- conditions within ten years has resulted in the
lowering of the death rate for almost twenty-nine mil-
lions of people, for consumption, 24 per cent. ; for typhoid
fever, 27 per cent.; for diphtheria, 50 per cent.; and for
malaria 54 per cent. The reduction of the general death
rate for the same number of ])eople means a saving of
almost fifty-two thousand lives, as well as the prevention
of an incalculable amount of sickness. The volume deals
with personal as well as public health, and is an invaluable
addition to the library, not only of the physician but also
of the layman.

The Joh.vs Hopkins Hospital Reports. Volume XI.

Baltimore: The Johns Hopkins Press, 1903.
This volume of the reports contains three monographs:
(i) Pneumothorax: A Historical, Clinical, and Experi-
mental Study, by Charles P. Emerson. A.B.. M.D. (2)
Clinical Observations on Blood-pressure, by Henry Wire-
man Cook, M.D., and John Bradford Briggs, M.D. (3)
The Value of Tuberculin in Surgical Diagnosis, by Martin
B. Tinker, M.D. The writer of "Pneumothorax" pre-
sents an exhaustive study of this subject. The first chap-
ter gives a historv' of numerous cases reported by many
different \\-ritcrs, going back to the earlier times. In later
chapters the history, etiology, and pathology, with the
clinical histories of cases, the mechanics of pneumothorax,
the symptoms, course, prognosis, diagnosis, and treatn'ent
of the disease are discussed. The authors of "Clinical
Observations on Blood-pressure." give the history of the
principal methods of clinical sphygmomanomctry ; blood-
pressure observations in svirgical cases, in obstetrical cases,
and in medical conditions. Thej- finally treat of the com-
parative value of general stimulant measures. In the last
paper, the value, dose, harmful use, injection, preparation
and reliability of tuberculin in surgical diagnosis are dis-
cussed.

The Practical Care of the Baby. By Theron Wendell
Kilmer, M.D,, .Associate Professor of Diseases of Chil-
dren in the New York School of Clinical Medicine ; .As-
sistant Physician to the Out-patient Department of the
Babies' Hospital, New York; Attending Physician to
the Children's Department of the West Side German
Dispensary-, New York. With sixty-eight illustrations.
Philadelphia: F. A. Davis Company, 1903.
The author has presented his subject in a clear, concise,
and interesting manner. He has gone into the explana-
tion of details in a most painstaking fashion. The text is
made very clear by numerous illustrations. The proper
development, clothing, and feeding of the infant are all
discussed. Then follow chapters on the diseases incident
to babyhood. Finally, there are sections treating of the
Nursery, the Wetnurse, Bad Habits, and Food Recipes.
The text is so plain that the book cannot help but be of
great ^-alue to mothers and nurses as well as to ohysicians.
A Manual of Clinical Diagnosis by Means of Micro-
scopical and Chemical Methods. By Chas. E.
SiMO.v. M.D. Fifth Edition, revised and enlarged.
New York and Philadelphia: Lea Brothers & Co., 1904.
Since its first appearance in 1896 this work has come to be
regarded as one of the standards in this country in its
particular field. The great strides made in this subject
during recent years have necessitated frequent additions
to the book in its successive editions, and the present one.
the fifth, has attained the dimensions of a large octavo
of almost 700 pages, with numerous illustrations. The
purpose of the book is well stated in the author's preface,
where it is said that exact methods of diagnosis necessarily
underlie successful therapeusis. and should therefore be
part of the equipment of every physician, Dr. Simon
has at tempted to simplify the physician's work and to in-
crease its efficiency by enabling him to eliminate doubt
from his diagnosis. Besides a careful revision, this edition
embodies much new matter which has appeared during the
last few years. The section on the blood has been entirely
rewritten and has been enlarged by sixty pages, especial
pains having been taken with the chapter on technique.
A section dealing with the nature of anihn dyes and the
principles of staining has been introduced. For con-
venience of reference, the subject of leucocytosis has been
arranged in such a manner that hypcrleucocytosis and
hypoleucocytosis are separately considered in connection
with the different varieties of leucocytes. .\ new section
deals with the cryoscopic examination of the blood. The
chapters on the parasitology and bacteriology of the
blood have been enlarged, with separate sections on
paratyphoid fever, gonococcus septicjemia. bubonic plague,
trypanosomiasis, and spotted fever. Many other additions
an'd changes have also been made in other sections.

July 2, 1904]

MEDICAL RECORD.

^nmtij SlfiinrtB,

NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, Held May 19, 1904.
Dr. Virgil P. Gibney, in the Chair.
The Distinctive Character of the Temperature Curve
of Measles, and of Scarlet Fever — the Treatment of Hyper-
pyrexia in These Diseases. — Dr. H. W . Berg read this
paper (see page i).

Dr. Henry Koplik said that the temperature curve
during the enanthemata could not be considered
exact as yet, because there had not been enough cases
under observation to warrant any conclusion. Dur-
ing the enanthemata there would be apparently a slight
rise of temperature, which might fall to normal, rise agafn
and, in two or three days, ■would rise further with
the appearance of the eruption. As to there being any-
thing characteristic about the prodromal stage he hesi-
tated to state; there was in all probabilit)- the tempera-
ture curve of an infection, same as would appear in an
attack of tonsillitis or other infections. Even before the
enanthemata there might be a slight rise, the child not
being apparently well, running a temperature of one-
half or one degree. There it was difficult to say when
the temperature curve began or when it ended. With
reference to the critical drop in measles he said that Dr.
Berg was correct in the chart drawings, but there were un-
complicated cases which did not show this critical drop ;
in other words, all cases did not conform to this critical
dropcurve, because there were many cases recorded without
any complications, so far as one could tell after the most
careful and painstaking examinations, in which the tem-
perature dropped by lysis. He could not, therefore,
support Dr. Berg's assumption that uncomplicated cases
of measles dropped by crisis. With regard to the state-
ment of Dr. Berg that he had never seen a case of measles
without temperature being present, he referred to a baby
that was under observation for six days, and he did not
know what the matter was. The baby was brought into
the hospital with a slight bronchitis, and for a day it
was watched carefuU}-. The temperature was normal,
being 99 . 4° by rectum. Soon the child broke out with
an eruption, there was a conjunctivitis, the spots were
well shown in the mouth, and the case proved to be
one of well-developed measles. The baby was transferred
to Riverside Hospital. Here was a well-marked case of
measles without scarcely any pyrexia.

In regard to the scarlet fever temperature curve, he
agreed with Dr. Berg that it acted as depicted by him in
normal cases, but he said he had seen cases with tempera-
tures of 103°, 104°, etc., which failed to drop, and when
there were no complications. In these cases there was
general enlargement of the lymphatic glands and a severe
dermatitis. He remembered distinctly just such a case
in which he was asked to point out the complication
which kept up the fever; he looked for it everywhere
but failed to find one. He thought it might be explained
by the fact that the desquamation was so marked,
and the glandular enlargement and toxaemia so marked
that it kept the temperature running a week or two.
He would endorse Dr. Berg so far as he had gone.
There was nothing so typical as a scarlet fever
normal curve, and nothing so varied as measles
when the eruption was at its height to predict whether
it would show a critical drop or not. There was another
class of cases that had not been referred to in which there
was no typical temperature curve at all, i.e. the malig-
nant cases with temperatures remaining at 105°, 106°.
To build a therapy upon the temperature curve he
thought would be rather risky, for each case should be
studied by itself. If left alone he believed the normal
cases of measles would get well: at the same time, if the
temperature remained up he did not hesitate to sponge
them and adopt mild measures. He did not recommend
cold sponging, but luke-warm water, as a rule. The

more he saw of scarlet fever the le.ss he felt that
he knew of its treatment, and he believed that each case
should be studied by itself. Lately he had seen a child,
six years old, who was very ill with scarlet fever, and
what helped this child more than anything else was
placing him in the cold pack and then adding cold water;
here no sponging was used. On the other hand, in pri-
vate practice, he treated his cases of scarlet fever with
sponging; some children bear cold sponging well with good
reaction, and others bear warm sponging well. Again
some children may go to pieces in a bath at 80°, but if
the water was raised to 100° it would revive them.

Dr. Alexa.nder Lambert said that his experience
coincided in the main with Dr. Berg's. Measles was as-
sociated with ^ distinct crisis, but the typical absolute
crisis, as depicted on the charts, was the exception rather
than the rule. When complications appeared, as a sud-
den attack of bronchitis, a temperature of 105° may be
reached within thirty-six hours. He referred to one girl
who had the typical rash, general adenitis, slight throat
symptoms, etc. It was a very brilliant rash, and the
case went on to complete desquamation at the end of
six weeks, and at no time was the temperature above
99°. In another case there was the red and congested
throat, the rash, adenitis, and a marked general desqua-
mation and no temperature. He agreed with Dr. Kop-
lik that in cases of scarlet fever, with very brilliant erup-
tions, in uncomplicated cases, the temperatures may
run along for two or three weeks before coming to the
normal.

Dr. Wm. p. Northrup said that measles, scarlet fever,
and smallpox had exact charts, and related an instance
in which he predicted what the chart would be in a child
who contracted the disease from her sister who was suf-
fering from scarlet fever. The thennometer should not
be studied so much but the child's condition. He ad-
vocated the use of water inside and out, and said that
the old adage, "keep the feet warm and the head cool,"
was a good one to follow.

Dr. Berg closed the discussion, and said that a great
deal hinged upon the question of complications, and
sometimes even the most astute clinician would overlook
a complication. The question of irregular temperature
curve at once raised the question as to the existence of
complications. He was interested in what Dr. Koplik
had stated regarding those cases which presented no
temperatures in measles. He was very skeptical regard-
ing such statements, because every case that he had
noted showed a temperature rise of from one-half to one
degree above the normal. With re.gard to scarlet-fever cases
he had seen children playing and seemingly enjoying life
when they had temperatures of 103.5°. He was skeptical re-
garding any acute eruptive disease going through its course
without temperature. In reference to the malignant
temperature curve of measles and scarlet fever he believed
the word malignant brought at once before one's eyes the
most toxic cases, and the high temperatures depended upon
the septic manifestations, and these cases he did not
include as being uncomplicated. By studying these
curves he said he was able to look for complications
which otherwise would have escaped his observation.

In regard to balneotherapy it was his custom to place
the patient in a luke-warm bath at 80°, and raise the tem-
perature about 10 degrees, thereby practically giving a
warm bath after a cold one; by so doing he got rid of
toxins, and the temperature would be lowered e\'en fur-
ther than if a bath at 60" had been given. He had seen
temperature of 105° drop to 99 . 5° after one of these baths
and stay there for nine or ten hours.

A Few Words Concerning Radium. — Dr. H. G. Piffard
read this paper (see page 999. Vol. 65).

Dr. Robert Abbe said that he wished to express his
opinion regarding this extraordinary agent, for he be-
lieved that there certainly was something in it ; it was a
\-erj' subtle agent, and was similar to the a:-ray, the ultra-

MEDICAL RECORD.

[July 2. 1904

violet, the Piffard, and Finsen rays. In its efficiency
it lay between the j;-ray and the Finsen light. Dr.
Abbe then reported certain experiments that he had
made showing the retarding effects of the radium upon
the growth of seeds; the results were unquestionable.
If twenty seeds were taken out that had been radiumized
four days, and twenty more that had been subjected to
its influence for two days, and twenty more that had not
been radiumized, if these seeds were planted for ten days
it would be shoisTi that the seeds unradiumized would
have grown seven inches, those that had been subjected
to its influence for two days woxUd have grown four
inches, and those radiumized four days would have growTi
only two inches. The retarding influence upon these
seeds as a result of the influence of radium was unques-
tionable. The same retarding effect was noted when
the meal-worm was subjected to the influence of radium.
Thousands of experiments had been made to show this
retarding influence in both the vegetable and animal
kingdom. Now if radium be laid upon the skin for a few
hours it will produce a welt-like urticaria; the next day
it will appear like a bum, and continue its effect, pro-
ducing a dry necrosis, scaling off and leaving a scar with
infiltration. A condition of necrosis and destruction
of the tissue cells are produced. Under the microscope
there will be found a leucocytosis, a thrombosis of the
small blood-vessels, the nerves will be infiltrated, the
leucocytes will infiltrate the tissues, all this excitation
being produced by radium. Dr. Abbe had experimented
upon himself and upon others. He found a suitable
case for experimentation in the mammary gland which
he was to amputate. There were two or three outlying
nodes in the skin, and he allowed the radium on the skin
for six hours on one place, then on another, etc., doing
this for six days, when he had pathological lesions run-
ning over a period of six days. He then took a piece of
radium and plunged it into the mammary growth, leav-
ing it there for twenty- four hours, and then amputated
the breast. The pathologist did the rest, and reported
the following facts: For a distance of one-quarter of an
inch there was a marked effect of the radium upon the
tissues. The nest-cells had begim to be disorganized,
and the superficial tissues of the skin necrosed. There
was a vascular leucocyte infiltration which was very
marked for one-quarter of an inch beneath in the mam-
mary tissue, and at right angles to the line of section;
there was a destructive necrosis of these nest-cells. The
pathologist said he wanted tissue showing the influence
of the radium for a longer period of time. He had an-
other patient with cancer, and by the application of
radium nineteen times in a period of three months he
reduced its size one-third, and then cut out one of these
cancerous nodules and gave it to the pathologist. Micro-
scopically there was shown a fibrous infiltration and a
reduction of the cancer cells, and the nest-cells were
present, but much smaller in number. It wai interesting
to note that one could produce practically the same effect
with a weak radium with longer applications, as with a
strong radium with short applications. Dr. Abbe re-
ported the case of a young man with a giant-celled sar-
coma of the lower jaw. Six months ago the gums be-
came swollen around the left lower canine tooth, which
became loose. Four months ago he sought advice at
St. Luke's Hospital. A soft spongy dark tumor occupied
the lower jaw from the middle portion toward the left,
and bulged inward under the tongue and outward under
the skin. It was so soft that it seemed to fluctuate. It
seemed to rise between the teeth. Three teeth were so
loose that they could be lifted from the sockets. A
radical operation was impossible without great deformity,
and with a surety that the growth would recur; there-
fore he decided to trj' the influence of radium upon it,
and this was applied over the growth within the teeth
for one-half to one hour daily, a lead shield protecting
the tongue. He next attacked the outer portion of the

tumor by laying the tube between the lip and the tumor ;
this so blistered the mucous membrane that he decided
to penetrate the tumor; he penetrated the tumor in its
\-arious parts, leaving the radium imbedded for two or
three hours at a time. The growth was not onh- arrested,
but there was an appreciable shrinkage in its bulk of
about one-third its size. The boy to-day was in apparent
perfect health. One week ago he took a trocar and re-
moved a cj'linder of tissue from the tumor, and examined
it microscopically, and it still showed that it was a giant-
celled sarcoma, but merely a shell. Dr. Abbe had the
influence of the radium upon the seeds, and the meal-
worms in his mind all the time, and he believed that he
had greatly retarded the grov^h. This was a vast prob-
lem; he believed that, although the cells develop they
can be held in check by radium, and he said what a tre-
mendous contrast was presented in this patient \vith
what would have happened if the growth had been un-
radiumized. Lupus and other conditions can be cured
by radium, and those using this agent were having suc-
cesses in various other conditions. A wart was a typical
hypertrophy of one of the layers of the skin, and prac-
tically a tumor. He had a patient with warts upon both
hands; on one hand he tried radium, and on the other
monochloracetic acid ; the warts disappeared from the
hands at the same time. Radium had an extraordinary
effect in producing a retrograde metamorphosis.

AMERICAN MEDICAL ASSOCIATIOX.

Fifty-fifth Annual Meeting, Held in Atlantic City, A^ J.,

June 7, 8, 9, and 10, 1904.

(Special Report to the Medical Record.)

(Continued from page 1065. Vol. 65.)

SECTION- ON OBSTETRICS AXD DISEASES OF WOMEN.

Third Day — Thursday, June 2, 1904.
The Surgical Treatment of Bilocular Uterus and Bifid
Vagina. — Dr. H. W, Lo.vgyear of Detroit reteiTed to the
meagre literature on this subject, and called attention to
the fact that as the malformation was easy of correction,
it should be operated upon as soon as discoN"ered, so as
to avoid the accidents of pregnancy and parturition which
are liable to attend this anomaly of development. Before
operating care was necessary in making a differential
diagnosis between uterus duplex and uterus bicomis.
The treatment recommended consisted in dividing the
septtim which separated the two uteri and vagina, and
creating one cavity. The septum was grasped between
clamps and cut ^\^th scissors, after which the Pacquelin
cautery was applied to the cut edges, and the cavity
packed with gauze. In the two cases which he reported,
dysmenorrhoea was a marked symptom, but was relieved
after operation, although in one of the cases an oophor-
ectomy had to be done subsequently.

Dr. Dunning of Indianapolis stated that he had seen
two cases of bilocular utenis and vagina. During labor
the septa were torn through. One was thin and offered
little obstacle to the progress of the presenting part; the
other was somewhat thicker. There was but light hemor-
rhage. Both cases did well, and he doubted whether an
operation was necessary, as a general thing.

Dr. Johnson of Washington had seen a case in which, if
operation had been done, much annoyance could have
been avoided. The woman had been curetted for an
apparent miscarriage and five months later was delivered
of another foetus. The condition was then found to be a
double uterus with a pregnancy in each.

Dr. Carstens of Detroit reported two cases with septum
which he divided, and although previously there had been
miscarriages, full term pregnancy resulted. To prevent
adhesions, he recommended the application of carbolic
acid to the interior of the uterus after operation.

A Plea for More Thorough Examination of Doubtful
Specimens of Ectopic Pregnancy.— Dr. J . W. Bo\' e e of Wash-
ington stated that many cases of ovarian and tubal hemor-

July 2, 1904]

MEDICAL RECORD,

rhage have a symptomatology precisely similar to dis-
turbed tubal or tuboovarian pregnancy, particularly
ttibal abortion. Specimens from such cases usually do
not receive precise examination and are considered as
pregnancy. For the sake of more reliable statistics, he
thought that more careful histological examinations should
be made. He reported ten cases in which the history indi-
cated tubal pregnancy, but this diagnosis was not con-
firmed by microscopical examination. In two, malignant
ovarian tumors were found.

Some Cases of Ectopic Gestation with Atypical Symp-
toms. — Dr. W. B. DoRSETT of St. Louis called attention
to the fact that many cases were occasionally found which
did not present characteristic symptoms. Thus a right-
sided tubal pregnancy might be mistaken for appendical
inflammation. He had operated on forty-one cases with
a mortality of six, and in some of these no diagnosis had
been made, but other indications were present calling for
surgical interference. He believed that the general con-
dition of the patient should be made the gviide for sur-
gical intervention and not alone the history of the case.

Dr. C.'iRSTENS of Detroit said that he had a case of sup-
posed appendicitis, without fever or increased pulse rate,
which turned out to have been a right-sided ectopic. He
claimed that it was right to operate first and decide the
pathology afterward.

Dr. M.\ssEY of Philadelphia entered a plea for more
conservative measures in dealing with ectopic gestation,
as in many cases nature had already begun the process of
obsorbing the mass when operation was undertaken. He
advocated the destruction of the foetus by the electric
current, where practicable, as an aid to this process.

Dr. GoLDsoHN of Chicago thought that the only diffi-
culty lay in diagnosing the cases before rupture. In some
cases microscopical evidence of the existence of a preg-
nancy covtld only be found in the cavity in the center of
the blood-clot. He considered that the idea of the
digestive function of the peritoneum was far-fetched.

Dr. HuMiSTON of Cleveland said that after rupture he
did not wait for subsidence of shock before undertaking
operation, but after injecting saline solution under the
breasts, he proceeded to carry it out immediately.

Dr. Dudley of New York considered that it was not
necessary to remove the entire tube for non-septic con-
ditions. After the foetus was turned out, the ovary and
tube could be dropped back, all occlusions, etc., having
been corrected.

The Influence of Ovarian Implantation on Menstruation
in Women. — Dr. A. P. Dudley of New York presented the
following points for discussion: (i) Is the operation justi-
fiable as a surgical procedure? (2) Is it worth the effort
from a physiological standpoint? (3) Will the transplanted
eventually resemble the fibroid in its action? (4) Is it
possible that pregnancy may ultimately take place? (5)
and provided it does, what is the prospect for normal
delivery? Thus far he had done this operation in seven
cases, all of which subsequently menstruated but at irreg-
ular intervals, and no physiological changes or nervous
manifestations resulted. One of his last cases he reported
in full. The patient had had both tubes and one ovary
removed, and for the relief of her symptoms, hysterectomy
had been advised, but to which she would not consent.
Operation was undertaken and the ovary freed from its
adhesions, but left attached by the ovarian ligament, was
implanted directly in the uterine cavity in a space pre-
viously gauged out in the muscular substance. Primary
union resulted and the woman menstruated three months
after the operation, and then, at intervals, every three
months. Eighteen months later she developed a severe
menorrhagia, and hysterectomy had finally to be done
three years after the first operation. Examination showed
that the ovarian and uterine tissues had become merged,
with Graafian follicles present. He was at a loss to ac-
count for the hemorrhages. The specimens obtained
from this case were presented at the meeting. The reader

doubted the extended applicability of the method, but
believed that it might be advantageously employed in
isolated cases.

A Plea for Conservative Operations on the Ovaries,
from a Neurotic Standpoint, with a Report of Cases. — Dr.

J. W. CoKENOWER of Des Moines read this paper, in
which he called attention to the necessity of making
a better diagnosis in those cases in which the symptoms
presented were ascribed to ovarian disorders. In many
instances it was questionable whether the trouble was
really due to the ovary. It was much more likely to
be an intoxication traceable to the intestinal canal, of
which the pelvic disease was the result, rather than the
cause. Neurotic cases were rare in which the symptoms
were wholly dependent on the sexual organs. It was
important to recognize when to conclude medical treat-
ment and institute surgical measures. The consensus
of opinion of many observers rather than the statistical
reports of a few, should be given preference. Negative
results for consen'ative ovarian operations for the relief
of neurotic conditions were common, and between the
two extreme views as to the advisability of operating,
an intermediate view was the best. He reported four
cases in which single or double oophorectomy and hyster-
ectomy had been done, with disappointing results. He
thought that in many cases we operated when we should
not have done so.

Dr. Morris of New York opened the discussion on
Dr. Dudley's paper. He discussed the advantages of
the procedure and the respective value of homoplastic
and heteroplastic transplantation. He had madenumer-
ous experiments on rabbits, and the latter method was
imsuccessful. He thought that it was well to save the
ovary in a case of pyosalpinx, and he foimd that the
organs could be kept in hot saline solution for several
hours without injury, before being transplanted and
while the remaining operative procedures were being
completed. In discussing Dr. Cokenower's paper, he
called attention to the fact that it was essential to care-
fully differentiate fundamental psychoses from neuroses.

Dr. GoLDSPOHN of Chicago opened the discussion of
Dr. Cokenower's paper. He thought the question might
be solved by distinguishing between psychical and actual
pain. Every other part of the body should be examined
before the pelvis. He had also invariably found that
pelvic lesions were aggravated by the erect posture or
anything else that favored congestion.

Dr. HuMiSTON of Cleveland found that frequently
the pelvic organs were normal and other organs accounted
for the neuroses. In discussing operative measures, he
stated that he onlj' attained good results from the com-
plete operations.

Dr. Bacon of Chicago thought that the site of implantation
was not favorable, as the implanted ovary might be
washed away by the uterine discharges. He believed
that the chief object was to secure the advantages of
internal ovarian secretion , rather than the possibilities of
pregnancy.

Dr. Massey of Philadelphia considered that in many
cases it was necessary to remove the inflammation rather
than the organ itself, and in this connection he believed
that kataphoresis with the mercuric ions valuable.

Dr. Carstens of Detroit thought that occasionally in
young women a favorable case for the Dudley operation
might be found, but that in older women it was best to
remove the ovaries if the symptoms were bad.

Dr. Craig of Boston had observed that the normal
ovary became scarred during middle life from cicatrization
of the continually rupturing Graafian follicles, and that
many so-called cystic ovaries, without clinical symptoms,
contained merely enlarged Graafian follicles. As it was
an essential thing to keep up the internal ovarian secretion,
he believed thatimder the proper circumstances, Dudley's
operation was favorable.

Dr. Chandler of Philadelphia thought that Dudley's

MEDICAL RECORD.

[Tuly

i(>04

operation presented many advantages and but few objec-
tions. Among the latter were the remote possibility
of sepsis, the death of the ovarj-. the production of mahg-
nancy, and the action on the fcetus. The main advantage
he considered to be the postponement of the meno-
pause.

A Series of Mistaken Gynecological Diagnosis. — Dr.
T. S. CuLLEN of Baltimore reported the following in-
teresting cases: (i) Was diagnosed as a large multi-
locular ovarian cyst, which at operation was found to be
a pedunculated fibroid, partially parasitic The omentum
was markedly atrophied and ascites was present. The
latter is extremely rare with fibroid conditions. (2) Here
the uterus was enlarged, globular, with apparently two
subperitoneal nodules. On account of the general his-
tory no examination of scrapings was thought necessary.
At operation an advanced adenocarcinoma of the corpus
was found. (3) Here a globular mass projected from
the right side of the uterus and from the vicinity of the
right comu a subperitoneal nodule. Both uterus and
nodules were movable and a diagnosis of intraligamentous
and subperitoneal myomata made. At operation the
subperitoneal nodule proved to be a tense and kinked
hydrosalpinx, the intraligamentary growth an adeno-
carcinoma of the ovary invading the bladder wall. (4)
This patient, aged sixty, presented temperatures from
100 to 103°. There was marked pain in the pelvis and
slight discomfort in defecation. In the vaginal vault,
and apparently attached to the posterior surface of the
uterus, was a slightly irregular but globular mass. The
diagnosis was between adhesions of subperitoneal myoma
glued to the pelvic floor and pelvic abscess. Operation
showed an irregvilar globular tumor involving the sigmoid
flexure. This had dropped over to the right side and
become adherent to the pelvic floor. Diverticulae were
filled with fecal concretions, and between the floor and
the growth was a small abscess due to rupture of a diver-
ticulum from the intestine. The tumor was benign.
(5) A case of adenocarcinoma of the kidney had been
well for sixteen months after operation. Then a rapidly
growing tumor was noticed in the hepatic region, which
turned out to be a neoplasm involving the lower half
of the liver, but was not a metastatic growth.

Injury to the Rectum in Gynecological Examinations. —
Dr. H. A. Kelly of Baltimore called attention to
the importance of the rectum as an avenue of investigation
and the obstacles encountered by this route. A rough
examination might readily rupture cystic structures and
spread their contents over the abdomen. He had also seen
several cases in which the finger was pushed through the
rectum and entered the abdominal cavity, necessitating
repair by laparotomy. In one instance it was found that
a large ovarian cyst had been punctured. The accident
depended not so much on the rough handling or careless-
ness of the examiner, as on the soft and friable character
of these tissues. In making a rectal examination, it was
always well to recognize, but not to invaginate the am-
pullae and to get the finger beyond what might be called
the third sphincter of the rectum. During an examina-
tion it was most essential that the arm be perfectly re-
laxed, and the wrist not held stiffly. Distending the
bowel with air also greatly facilitated the examination.
When injured, the rectum might be repaired through the
posterior cul-de-sac, or, if advisable, by the abdominal
route. He asked that cases of this kind be put on
record.

Dr. Wetherill of Denver called attention to the possi-
bility of injuring the rectum during the conduct of a labor,
when the operator's finger was inserted into the rectum
to support the advancing fetal head. Dr. Cullen of
Baltimore reported two cases in which the rectum had been
injured. Dr. Shoemaker of Philadelphia mentioned an
instance in which an appendical abscess had been ruptured
by the hydrostatic pressure of an enema, and Dr. Noble
of Philadelphia also reported a case of pelvic abscess
ruptured by rectal examination.

Some Further Observations on the Use of the Stem
Pessary for Scanty and Painful Menstruation. — Dr. J. H
C.^RSTExs ot Detroit stated that in a certain class of cases
these conditions could only be ascribed to lack of exercise
of the uterine muscle. He thought that the organ could
be sufficiently well developed by the introduction of a
foreign body which the uterus would constantly endeavor
to expel. In another class of cases, dysmenorrhosa comes
on later, after normal menstruation for years, in which the
uterus, and especially the cervix, had undergone premature
atrophy. All these cases might be relieved by the intro-
duction of a stem pessary. In one of his cases the stem
had been in place for two years, but after removal a
gradual return of her symptoms took place, which was
finally relieved by the reintroduction of the instrument.
In another case of sterility of five years' standing, preg-
nancy came on after the use of the stem for a few months.

The Propriety, Indications, and Methods for the Termina-
tion of Pregnancy. — Dr. F. A. Higgi.ns of Boston believed
that there were evidences of broadening of the indications
for the termination of pregnancy, and the wisdom of this
could not be questioned. The question remained whether
this would lead to ill-advised abortion, but he felt safe in
stating that he did not think it would. He discussed in
detail the influences exerted by the various acute and
chronic diseases. An acute disease was not usually an
indication, but if labor comes on, it should be hastened.
The religious question was also touched upon.

As for the methods, he considered bougies favorable in
certain cases, but thought it better to employ two than
one. He recommended, however, the Vorhees bag and
the colpeurjTiter. Manual dilatation was accompanied
by the danger of rupture. Instruments, he claimed, were
under more complete control, and therefore more secure.
The dilatation in each case depends on the amount of
stretching which the cervix ■will endvu-e. The Bossi
dilator was shown and discussed, and the author's newly
modified instnoment presented. This was more compact
than the Bossi and claimed to be less dangerous. It might
also be used for dilating the cervix before ordinary
curettage.

Dr. H.\ll of Kansas City said that he thought it was
more honorable to suggest methods of preventing preg-
nancy in questionable cases rather than to devise methods
of abortion. He believed that the effect of such a paper
might be bad on the public mind. Where the necessity
existed, he considered that the instrument was preferable
to the use of the fingers.

Dr. B.\co.Nr of Chicago claimed that the social condition
of the patient should be largely taken into account in
deciding the advisabiUty of abortion. In the case of
hydramnion and twins, he advised rupture of the mem-
branes, and the bag, when used, should then be placed
within the egg sac. In his opinion, vaginal cssarean
section was to be preferred to the use of instruments.

Adherent Uterus as a Complication of Labor. — Dr. J. C.
Appleg.ate of Philadelpliia discussed the circumstances
imder which the pregnant woman with adherent uterus
should be allowed to go to full term, and the best method by
which such complications could be treated. He found
that the round ligament suspensory operations had no
effect, but that labor quite fully destroyed the results of
the previous operation. Peritoneal suspension was dan-
gerous from possible ruptxu^ of the uterus. Ventral fixa-
tion was unjustifiable before the menopause, except tinder
rare circumstances. Before attempting the latter opera-
tion, amputation of the cen-ix should always be done.
In vaginal fixation he believed that labor should be in-
duced. With ventral fixation, pregnancy to full term
depended on the mobilit}' of the uterus; if the cervix failed
to enlarge and rose posteriorly, labor should be induced.
The safest thing for these cases, however, was considered to
be cesarean section. In the reader's estimation the best
method of suspending the uterus was by sutures intro-
duced in front of the origin of the tubes instead of to the
fundus. Two cases were reported, in one of which the

July 2, 1904]

MEDICAL RECORD.

adherent uterus was the cause of pernicious vomiting, and
mechanical intestinal obstruction. Labor was induced at
seven months, and was accompanied by uterine inertia
and post-partum hemorrhage. The cause of the adhesion
had been parametritis following a previous abortion. In
the other case there was an adherent uterus following
ventrofixation, perineorrhaphy, and amputation of the
cervix, thirteen months pre\-iously.

Dr. Dunning of Indianapolis stated that he had done
suspensory operations in 165 cases, eight of which became
pregnant and terminated the same without complications.
He suspended the uterus by three sutures, which formed one
band between the organ and the anterior abdominal wall.
Dr. Fry of Washington had 150 cases, with fifteen
cases of pregnancy, without complications and without
any subsequent return of the prolapse. He thought
the Alexander operation unsuitable, as it was apt to be
followed by dragging on the round ligaments.

Membranous Endometritis. — Dr F. F. L.\wrence of
Columbus referred to unsatisfactory results obtained
from local treatment in this condition and proposed more
radical measures. In forty-two cases seen he noted that
tubal or ovarian disease were almost always present. In
a considerable number the ovarian disease appeared to
have followed the exanthemata. He belie\-ed that mem-
branous endometritis was probably a secondary trophic
disturbance due to the presence of an intercurrent pelvic
disease, and suggested that when the condition of the
tubes and ovaries was not due to infection, a cure of the
endometritis might be secured by removing the diseased
structures without in any way treating the uterus itself.
He had successfully accomplished this result and rec-
ommended further and more extended trials. In all
cases of membranous endometritis, which he considered
a more appropriate term than membranous dysmenor-
rhoea, a careful examination should be made with these
points in view.

Dr. Fischer of Philadelphia thought the expulsion
of shreds only not sufficient evidence to warrant the
diagnosis of membranous endometritis, and said that
among a large number of cases he had only observed two
instances of this disease. He marvelled at the large
number of cases observed by the writer.

Dr. Lawrence said that he did not propose this as an
absolute recommendation, but offered it as a suggestion
which had been borne out by facts. Many of his cases
had expelled complete casts; but even the presence of
shreds, he claimed, was sufficient to stamp the condition
as a true membranous endometritis.

Management of the Acute Infective Stages of Abdominal
Inflammation. — Dr. G. E. Shoemaker of Philadelphia
read this paper, which might be summarized as follows:
in some acute abdominal inflammatory types of disease,
operate radically unless there is good reason for the
contrary. As an example of this, he quoted appendicitis.
In other types do not operate radically in the acute stage,
unless there is good reason for the contrary, but operate
in subacute or the chronic stage. Example of this was
gonorrhoeal salpingitis. Individual cases of all types
of disease should be watched by a trained eye, as disaster
was apt to follow any fixed rule. He concluded by
noting the signs which point to operation and also measures
useful in non-operative cases.

The officers of the section for the ensuing year, as
selected by the Committee on Nominations, were as fol-
lows; Chairman. Dr. C. L. Bonifield of Cincinnati; Vice-
Chairman, Dr. F. F. Lawrence of Columbus; Secretary.
Dr. Manton; Delegate, Dr. J. W. Bovee of Washington.

SECTION IN SURGERY.

Third Day — Thursday, June 9.
The Anatomy of Inguinal Hernia; Andrew's Operation
for Radical Cure. — Dr. D X. Eise.vdr.\th of Chicago
dealt with the general considerations on the anatomy of

this subject, which he demonstrated by a very ingenious
model explaining the objects to be accomplished by a
radical cure. He gave his experience with the Andrew's
operation and freely illustrated his paper by models
and charts.

Three Years' Experience with the Autoplastic Suture
for Hernia. — Dr. L. L. McArthur of Chicago gave a
final report of his experience with this suture, and stated
that three years' experience with its use in inguinal hernias
encouraged the continuance of its employment. As a
result of trying it in ninety-three cases and as judged by
the histological findings in experimental work, he was
justihcd in claiming that the transplanted tendon lived.
He demonstrated this fact by an examination of the scar
of a patient dead of a subsequent appendicitis a year
after having an autoplastic suture.

Surgery of the Trifacial Nerve and Its Ganglia. — Dr. John
B. Murphy of Chicago went very fully into this subject,
which he divided into five stages: (i) Resections of
branches down to the cranial foramina. (2) Division
of branches within the cranium, with efforts to occlude
the foramina. (3) Removal of the Gasserian ganglion,
with intracranial segments of nerve. (4) Extraction
of sensory root, and ; (5) intraneural injections, and
made clinical reports with the result in eleven cases

Intracranial Neurectomy for Trigeminal Neuralgia,
Cases and Comments. — Dr. Harry M. Sherman of San
Francisco gave a brief report of five operations on four
patients, in three of which uneventful recoveries from the
pain were secured. He mentioned some slight modifica-
tions in the incisions of the soft parts and of the bone, and
recommended the pouring of salt solution into the skull
before the suture to fill all vacant spaces and exclude the air.

Summary of the Final Results of Four Cases of Division
of the Sensory Root for Tic Douloureux. — Dr. Charles
H. Frazier of Philadelphia spoke of the theoretical
advantages of this method over operative procedures and
showed the immediate results obtained. He claimed to
have had no evidence of recurrence, one, two, and three
years after operation.

Dr. Charles K. Mills of Philadelphia, Dr. Walter
G. Spiller of Philadelphia, Dr. Robert F. Weir of New
York, Dr. J. Shelton Horsley of Richmond, Va., Dr.
Cushing of Baltimore, and Dr. John B. Murphy of Chicago
discussed these papers from \arious points of view, the
general conclusions being that the relief of the condition
was not as yet an assured fact by any of the methods
mentioned, and Drs. Sherman, Murphy, and Frazier
closed the discussion.

Laminectomy: A Further Contribution. — Dr. John C.
MuNRO of Boston reported from twenty-five to thirty
cases of laminectomy and pleaded for the simplification
in the technique as being important in reducing the
severity of the operation.

Dr. Lund of Boston and Dr. Cushing of Baltimore
complimented the author on his excellent results and
heartily endorsed the points he made.

Treatment of Cold Abscesses and Sinuses in Tuberculous
Disease of Bone. — Dr. V. P. Gibney of New York
took up the routine surgical treatment of the day and
dwelt extensively on the orthopedic treatment, bacterio-
logic findings, value of asepsis from beginning to end, and
comparative results of the methods employed.

Old Unreduced Dislocations. — Dr De Forest Willard
stated: (i) Early immediate diagnosis was the most
important element in the prevention and treatment of all
dislocations. With ether, the «-ray and anatomical and
surgical knowledge, the displacement should always have
been discovered by the surgeon. His only excuse for
non-recognition would have been extreme injury in other
portions of the body. (2) An unrecognized or unreduced
dislocation should have been carefully examined under
ether to discover the extent of adhesions and the possibiHty
of affecting reduction without measures; failing in this,

MEDICAL RECORD.

[July 2, 1904

continuous extension in he^ should be practised for several
weeks; the second attempt, without the application of
extreme force, should be made, the permission of the
patient having been previously obtained to permit of open
operation if deemed necessary. (3) Open section should
include the division of all muscular, tendinous, capsular,
and bony obstacles to reduction. When the socket is
filled up with dense fibrous tissue, such tissue should be
excavated and the head of the bone displaced iit situ.

(4) Partial or complete excision of the head and of
fragments in case of fracture, was frequently necessary.

(5) In cases that had existed more than a year, or in which
the original injury had been extreme, operation should
be avoided unless pressure upon nerves or blood-vessels
was seriously impairing the usefulness of the limb or
giving pain. Resection should be reserved for bad late
cases with pain and serious nerve symptoms. Sepsis
was frequent on account of the severity and length of the
operation. (6) Pain and disability were the two most
important measures in arriving at a decision concerning
operation. When a limb was useful in its new position,
gave no pain or difficulty, it should be left alone. (7)
In the after-treatment, muscular gymnastics, electricity,
and massage were very important measures and sl»uld
be persistently employed.

Conservative Perineal Prostatectomy: Report of Fifty
Cases. — Dr. Hugh H. Young of Baltimore called es-
pecial attention to the absence of mortality and the
simplicity of the procedure, many of the patients being
over seventy-five and some over eighty years of age, and
laid stress on the importance of cystoscopy and careful
preliminary treatment.

Prostatic Obstruction. — Dr. Parker Sv.ms of New York
read a fully illustrated paper on this subject.

Prostatectomy in General, Especially by the Perineal
Route. — Dr. George Goodfellow of San Francisco gave
the indications for his adherence to the perineal route,
described his method of operating, referred to the mor-
tality in seventy-five cases operated upon by this
method, and gave the ultimate results of each.

Is It Wise to Try to Make Any One Operative Method
Apply to All Prostatectomies? — Dr. Eugene Fuller < !
New York read a paper so entitled, which he opened by
stating that the results obtained by prostatectomy had
put the operation on a firm footing. Numerous surgical
makeshifts were brought forward, when the operation was
first introduced, to compete with the radical operation.
Most of these had now been discarded, owing to the un-
satisfactory results attending them and to the increasingly
better results following prostatectomy at skilled hands.
The criticism was ma<le that most of the present ■writers
on the subject concerned themselves only with the prob-
lem of operative removal of the prostate, the questions of
after treatment and general management receiving little
or no attention. All prostatectomies were grouped under
three headings: (i) W'here the hypertrophy is removed
through the employment of a suprapubic cystotomy ; (2)
where it is removed through the employment of a perineal
cystotomy; and (3) where it is extracted along the path
of a perineal dissection, the aim of which is to avoid
opening the urinary tract or the rectum. As far as the
mere removal was concerned, he stated that it could be
done by any one of the three methods, and then discussed
the pros and cons of the different methods, but few cases
were found in which the third method seemed ad\isable.
When performed according to Dr. Fuller's ideas the second
method was ad\ocated for most cases in connection with
which there existed good expulsive force to the bladder.
Where this was impaired and where serious lesions of the
urinary tract existed the suprapubic operation was the
one usiially chosen. He called attention to the fact
that most writers showed a strong tendency to try to
make some special form of the perineal operation apply
to all cases and to entirely discard the suprapubic opera-

tion on the ground that it was either unnecessary or
operatively extrahazardous. These objections were ably
met. The suprapubic operation, it was asserted, should
in itself give no extra mortality if certain rules were ob-
served in its performance, if the incision was properly
sutured and drained, and if the surgical supervision of the
after-treatment was efficient. The value of the supra-
pubic vesical drainage vent, a feature connected with the
suprapubic operation, was especially dwelt upon. The
establishment of such a vent. Dr. Fuller stated, decided
him to choose the suprapubic operation in a certain class
of cases. In conclusion, a protest was entered against
classing as true prostatectomy cases of middle-aged or
even younger men which represented simple inflammatory
effusions in connection with the prostate or its periphery.
In such cases an operator attempting prostatectomy would
find nothing to enucleate, or for that matter to remove.

Dr. Orville Horwitz of Philadelphia, Dr. Robert H.
M. Dawbam of New York, Dr. John C. Munro of Boston,
Dr. Martin B. Tinker of Cornell, Dr. D. N. Eisendrath of
Chicago, and Dr. Archibald McLaren of St. Paul freely
discussed these papers and endorsed most of what had
been said, the authors closing.

Kidney Stone; Diagnosis and Treatment. — Dr. Arthur
D. Bevan of Chicago took up the question of etiology,
symptoms, differential diagnosis, prognosis, technique of
operative procedures, and the question of recurrence after
operation.

Fourth Day — Friday, June 10.

The Treatment of Fractures of the Patella by Lateral
Sutures. — Dr. Jos. A. Blake of New York dwelt fully on
the anatomy of this subject and reported the resiilts of
eighteen operations both as to union and as to function
according to his method.

Surgical Treatment of Certain Cases of Arthritis Defor-
mans. — Dr. Martin B. Tinker of Ithaca, N. Y., presented
this paper and stated before beginning a discussion|on this
subject that it was necessary to keep in mind the exact char-
acter of the disease under consideration. He said the
condition was not a subacute or chronic rheumatism or
tuberculosis, but a distinct diseased condition character-
ized by its long course, with progressive involvement c f
many joints, which lead eventually to absolute disability
from ankylosis. Many interesting suggestions, he stated,
had been made as to the etiology of the affection. In some
cases it followed severe nerve-strain, and the nervous ele-
ment was no doubt an important factor. Disturbance of
metabolism, he stated, was also always present, but these
were probably only contributing factors. The infectious
origin seemed most probable, as several cases had been
observed in which the disease had developed directly
after a severe infection. He stated pain, swelling, and
stiffness of the joints were the most important symptoms;
the pain gradually ceased as the joints became fixed. The
swelling at first was from effusion, but this would soon dis-
appear, and later the enlargement was from bony or fibrous
thickening. He stated that the use of tuberculin was of
great value in the diagnosis in distinguishing it from tuber-
culosis, a condition with which it might be confused. He stat-
ed that in the treatment both palliative and operative meas-
ures should be considered; as a rule, the general principle
followed in the treatment of joint trouble, to put the joint
at rest, was reversed, for if the joint was kept quiet,
stiffening was certain to occur at once. Gymnastics,
massage, and passive motion were to be judiciously em-
ployed; baking at from 280' to 350° Fahrenheit was of
value, as were also the use of various forms of baths;
general hygienic measures were also of importance. In
the operative treatment forced motion under ana:'Sthesia
was condemned, for the stiffness was not from adhesions,
but from bony deposits and change of the contour of the
bones affected. Arthrotomy and excision of osteophytic
deposits might be employed where the stiffness of the

July 2. 1904]

MEDICAL RECORD.

joint was dependent upon the pressure of only one or two
such bony prominences that lock the joint and where the
acute symptoms had entirely subsided. Excision of the
joint was indicated in cases of complete ankylosis, to
restore motion, and often enabled the patient to feed and
dress himself and perform other necessary duties impos-
sible with an ankylosed joint. He stated that operative
treatment was limited to a comparatively few cases of
this kind. The condition was generally a most pitiable
one and the general condition was incvu-able.

Impacted Fractures of the Neck of the Femur. — Dr.
Le Movne Wills of Los Angeles reported two interesting
cases, which he illustrated with radiographs. He laid
particular attention on the marked difference in treatment
jn each case and to the good results obtained.

Fat Embolism of Lung, Following Fracture, with Report
of Two Cases. — F. Gregory Coxxell, M.D., of Leadville,
Co!., reported two cases of fat embolism of the limg which
followed fractures of the long bones, both of which recov-
ered. In a study of the history of the subject he found
that about 250 cases had been reported, and of these not
over a dozen had been contributed by American writers.
The anatomy of the parts involved was reviewed, and
among the causes other than fracture are envimerated
orthopedic operations, open operations upon bones and
joints, surgical operations on structures other than bone,
inflammation of bone or periosteum, laceration, bruising
or suppuration of the fat containing soft parts, or exten-
sive bums or scaldings, rupture of fatty liver, and also
causes that had arisen within the circulation, such as
atheromatous changes of the vascular wall, fatty changes
of the thrombi of various origin and location, diabetes,
icterus, etc. The symptomatology was considered at
length; the milder form was rarely diagnosed, and was
of little import; the acute and rapidly fatal form was
rarely differentiated from shock, and was often unsus-
pected. The ordinary form of fat embolism, that was
recognized as such, usually presented the following symp-
toms : An interval of euphoria ; lipuria or fat in the
sputum; extreme debility, anxiety, malaise, somnolence,
pallor, cyanosis; respiration, rapid and irregular, with
dyspnoea, cough, pain, hsmoptysis, rales, oedema, or con-
solidation; pulse, feeble, irregular, and rapid; temperature
unreliable; loss or diminution of sensibility, and of the
reflexes, pupils contracted, Cheyne-Stokes respiration,
spasm, convulsion, vomiting, paralysis of coma. Each of
these are considered pro and con, but the temperature,
which was perhaps the most perplexing and unsettled
symptom of fat embolism, was gone into at length, and
it was concluded that the temperature might be high — in
thirty -seven cases in which the temperature was given,
that were collected from the literature, twenty-nine had
an elevation of the temperature, while in the eight the
temperature was mentioned as being either normal or
subnormal. The diagnosis during life was first made by
Lucke, and in the same year, 1S73, by Bergman; the first
in America to diagnose the condition during life, was
the late Christian Fenger. in 1879. Among the conditions
more likely to be confused with fat embolism might be
mentioned: Shock, septicsemia, pulmonary embolism, and
less commonly, the effects of anaesthetics, congestion of
the Ituigs or kidneys, cerebral hemorrhage, concussion of
the brain, atheroma of the coronary arteries. The prog-
nosis was most uncertain, owing to the fact that the
frequency of the condition was tmknown. Fat embolism
of a greater or lesser degree followed practically all frac-
tures, but it gave rise to serious symptoms comparatively
seldom. The fat in the circulation had no deleterious
effect upon the blood; its sole action was a mechanical one,
in obstructing the capillaries. The treatment was un-
satisfactory — in fact, it might be said that there was no
treatment. Prophylaxis would consist of gentle handling
of the limb, so as to rupture as few fat cells as possible,
and then immobilization. After the symptoms were
present, drainage, as it lessens the tension at the site of

the injury, might be of advantage. But the closest at-
tention should have been given to the heart, and as the bulk
of the fat was eliminated through the kidneys, attention
should also have been given to these same organs.

ClN'ClNN.\TI AC.\DE.\IY OF MeDICINE.

At a regular meeting of the Academy, held on April iS.
Dr. B. Merrill Ricketts presented four cases. A case of
excision of the elbow-joint for ankylosis with an excellent
result and three cases of hernia, one a double inguinal
hernia with perfect result and two cases in which three
operations had been necessary before a good result was
secured. Dr. Ricketts laid the failure of the first two
operations in each case to the use of faulty sutures. Dr.
Edwin Ricketts showed a tube and ovary removed from a
woman in the chilcVbearing period. She had had several
attacks of severe pain with some bloody discharge from the
uterus. On removal, the tube was found distended with
blood and was believed to be an extrauterine pregnancy.
Microscopical examination had not yet been made.

The paper of the evening was read by Dr. John E.
Greiwe entitled, "Aortic Lesions." He said in brief:

Our greatest advance in the comprehension of aortic
lesions has come from the study of their etiology, and we
will do most good by using this knowledge in their pro-
phylaxis and treatment. Lesions of the aortic orifice
are always of grave importance and are always very
difificult to manage. The increase of blood pressure in
the left ventricle with the necessary increase of labor
involved the tendency to degeneration of the muscular
wall, the greater danger of cerebral involvement and the
frequent involvement of the mouths of the coronary
arteries are some of the special dangers of these lesions.
In these cases we must study not the heart alone but the
condition of the whole circulatory system and the remote
organs. Of S54 autopsies at the Cincinnati Hospital, 160
showed well-marked heart lesions, 43 involved the mitral
valves alone, 42 the aortic valves alone. In 38 both
mitral and aortic valves were diseased. In two cases the
tricuspid valves were diseased in combination with disease
of the mitral and aortic valves. Sixteen cases showed peri-
carditis, 10 with adhesions; of these 10, five were asso-
ciated with aortic disease and two with mitral. The
remaining 19 cases showed muscular change or disease of
the coronary arteries. These figures show the relative
frequency of aortic and of combined lesions.

Known causes of aortic lesions are acute infections,
especially acute theumatism and scarlet fever, alcoholism,
syphilis, gout, hard manual labor, sudden severe strain,
lead poisoning, nephritis, excessive use of coffee and
tobacco, chronic intestinal autointoxication, and last but
not least, conditions that give rise to long continued and
oft repeated high tension in the circulatory apparatus.
Chronic poisoning from whatever cause destroys the
elasticity of the blood-vessels, hard labor and long con-
tinued stimulation by coffee, tea, and tobacco cause high
tension and later impair the elastic coats of the vessels.
Sudden strain may cause n.ipture of valves with regurgita-
tion and sudden collapse. Of all causes or associated
conditions, nephritis is most important, and of 160 cases,
89 showed marked kidney change, mostly interstitial, but
parench\-matous changes and pj-elonephritis were not
micommon. The importance of uranalysis in these cases
and the good effects of diet and eliminative treatment are
well loiown.

In regard to long continued and oft repeated high
tension, there can be httle doubt that the heart re-
sponds to all the emotions of the central nervous system,
and the writer believes that profound emotions, such as are
almost constantly present in cases of hysteria, neuras-
thenia, melancholia, etc., are frequently, by raising the
blood pressure, responsible for disturbances which at first
may be purely fvmctional. but later may produce organic
changes in the blood-vessels and secondarily in the heart
itself.

MEDICAL RECORD.

[July 2, 1904

The real etiology and patholog^y of these cases is still
Tincertain, but it is certain that long continued high tension
leads to a loss of elasticity in the middle coat of the arteries
with changes in the intima and tremendous backdamming
on the aortic valves. No fruits may be present for a long
time, but the second aortic tone is much accentuated and
tachycardia is frequent.

The writer has taken sphygmographic tracings and
■measurements of blood pressure in a number of these
■cases. Miss C, thirty-four years, suffering from neuras-
thenia, has very high blood pressure with the Riva Rocci
instrument, 228; Gaertner, 200; and Basch 215. Pulse 88,
second aortic tone much accentuated. Elastic waves
are poorly marked in the tracing, showing loss of elasticity.
Miss S., age thirty, also suffering from neurasthenia with
"high tension. Pulse 116, Riva Rocci 133, Basch 120, and
Gaertner no. In this case the fiftt aortic tone was
roughened and the second accentuated, the elastic waves
■of the tracing were diminished. The patient is subject
to attacks of tachycardia with semi-consciousness and
lividity. Both tracings show the "ptilsus tardus" of high
pressure. Other sphygmograms from aortic lesions were
■shown, showing well-marked "pulsus tardus," and in one
instance "pulsus rotundo tardus" due to high tension and
loss of elasticity in the blood-vessels. In one tracing a
•well-marked "water-hammer pulse" was shown.

As regards treatment, prevent the trouble as far as
possible by treating the predisposing conditions. When
the trouble has begun prevent further damage by attention
to diet, hygiene, medication, and regulation of the work
to be done. Avoid strain, physical and I'nental. As
said above, high pressure is often responsible and should
1)6 relieved by attention to the kidneys, and often the
intestinal tract will be found to l)e the exciting cause.

Venus stasis should be relieved by mild exercise or
passive movements, and systematic breathing exercises
should be carried out. The Nauheim treatment relieves
liigh tension by bringing about a freer flow through the
capillaries, and can be carried out at home by the use of
3. powder prepared for the author in this city.

Following the paper. Dr. Greiwe demonstrated a
number of pathological specimens from the Cincinnati
Hospital Museum and several instruments for measuring
Islood pressure.

While the Medical Rkcord is flcasci to receive all
new {Publications which may be sent to it, and an acknowl-
edgment will be promptly made of their receipt under this
heading, it must be with the distinct understanding that
its necessities are such that it cannot be considered under
obligation to notice or review any publication received by
it witich in tlie judgment of its editor will not be of interest
to its readers.

Beitrage zur Klinik der Tuberkulose. Herausge-
geben von Dr. Ridoi.ph Bracer. Band 2, Heft 4. 8vo,
pp. 251-364. A. Stuber, Wurzburg, Germany.

Obstetrics and Gynecolooic Nursing. By Edward
P. Davis, A.M., M.D. Second edition, revised. i2mo,
402 pages. Illustrated. Muslin. W. B. Saunders &
Company, Philadelphia. Price, $1.75 net.

Epilepsy and Its Treatment. By William P.
Spratling, M.D. 8vo, 522 pages. Illustrated. W. B.
Saunders & Company, Philadelphia, Pa. Price, cloth,
44 net.

American Edition ok Nothnagel's Practice: Tuber-
culosis AND Acute General Miliary Tuberculosis.
By Dr. G. Cornet. Edited, with additions, by Walter
B. James. M.D. 8vo, 806 pages. Muslin. M. B.
Saunders & Co., Philadelphia, Pa. Price, S5 net.

Clinical Treatises on the Pathology and Therapy
OP Disorders of Metabolism and Nutrition. By
Prof. Dr. Carl VON NooRDEN. Part V. i2mo, 92 pages.
Muslin. Edited by Boardman Reed, M.D. E. B. Treat
& Company, New York.

Beitrage zur Pathologie und Therapie der Pan-

KREASERKRANKUNGEN MIT BESONDERER BeRUCKSICHTI-

GUNG DER Cysten UND Steine. Von Privatdocent Dr.
Paul Lazarus. Band 51 und 52. 8vo. 208 pages.
Illustrated. August Hirschwald. Berlin.

Mthiml Strata.

Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious diseases reported to
the Sanitary Bureau, Health Department. New York
City, for the week ending June 25, 1904:

Measles

Diphtheria and croup

Scarlet fever

Smallpox

Varicella

Tuberculosis

Typhoid fever

Cerebrospinal meningitis

Casa

Deaths

464

455

181

,1/0

171

Health Report. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the Surgeon-General, U. S Marine Hospital Service,
during the week ended June 25, 1904:

SMALLPOX — UNITED STATES.

Colorado, Denver Apr. 16-May 2S.

Delaware. Wilminijton June r 1-18

Florida, Jacksonville June i i-i8

Georgia. Macon June 11-18

Illinois. Chicago June ii-i8

Louisiana, New Orleans June i x-i8

Maryland. Baltimore June 11-18

Michigan. Detroit June 1 1-18

Missijuri. Saint Louis June 4-18

Nebraska, Omaha June 1 1-18

South Omaha June i i-i

CASES DEATHS
14

New Hampshire. Manchester June 11-18.

New York, Buffalo June n-i8.

Ohio, Cincinnati June 3-17 ■

■!"

-Ju
.lu
■ Ju

.Ju

•J"

Dayton June 1 1-18.

Hamilton June 7-14.

Pennsylvania. Altoona June 11-18.

Philadelphia June 11-18.

South Carolina. Charleston June 11-18.

Tennessee, Memphis June 11-18.

Nash\'ille June 1 1-18.

Wisconsin, Milwaukee June 1 i-i8.

33
106

SMALLPOX — INSUL.\R.

Philippine Islands, Manila April 30-May 7.

S.MALLPOX — FOREIGN.

Austria, Pra;:iue May

Belgium, Antwerp May

Rrazil. Pemambuco May

Rio de Janeiro May

Canada, Vancouver May

France. Lyons May

Paris May

Gibraltar May

Great Britain, Birminsham May

I Bradford May

Bristol Mav

Cardiff May

Dundee May

Edinburfih May

Glasgow June

Hull May

Liverpool May

London May

Manchester May

New-Castle on-Tyne May

Nottingham May

India, Bombay May

Calcutta May

Karachi May

Italy, Milan April

Palermo May

iapan, NaKasaki May
texico. City of Mexico May

Vera Cruz May

Netherlands, Amsterdam June

Panama, Panama June

Russia, Moscow May

Odessa May

Warsaw April

Turkey, Constantinople May

YELLOW FEVER.

Brazil, Rio de Janeiro May 8-2j 19 S

Mexico, Merida June s- 1 1 i

Tehuantepec June 5-11 S »

Vera Cruz May 28-June 4 3

Hawaii, Honolulu June 10

Philippine Islands, Manila April jo-May 7.

-June 4 • Imp'ted

40
3

PLAGUE — FOREIGN'.

Egvpt May 14-21-

India, Bombay May 18-24-

Calcutta May 14-21 .

Karachi May 15-22.

36
160
134

CHOLERA.

India, Calcutta May 14-21

Madras May 14-'°

Medical Record

A Weekly Journal of Medicine and Surgery

Vol. 66, No. 2.
Whole No. 1757.

New York, July 9, 1904.

$5.00 Per Annoir.
Single Copies, lOc.

©rtgtnal Arttrl^H.

ILLUMINATING GAS POISONING: A CLINI-
CAL STUDY OF NINETY CASES.*

By W. oilman THOMPSON, M.D.,

NEW YORK.

PROFESSOR OF .MEDICINE IN THE CORNELL UNIVERSITY MEDICAL

COLLEGE IN NEW YORK CITY.

In view of the frequency and seriousness of poison-
ing by illuminating gas, it is a surprise that the con-
dition has not received more attention in medical
literature, for it presents a number of interesting
phenomena, such as an eccentric fever, a high degree
of leucocytosis, and a large group of nerve symptoms,
besides various practical problems. It has been my
experience to meet with three fatal cases and a num-
ber of others in private practice besides many in
hospital service. The conclusions herewith pre-
sented are based upon a study of ninety cases, a large
proportion of which were treated at the Presbyte-
rian Hospital in the service of my colleagues or
myself. This series of ninety cases includes twelve
in which autopsies were performed. None bvit com-
atose cases have been included, and of the ninety
cases only seventeen, or 18.8 per cent., were fatal.

The lack of systematic nomenclature and cooper-
ation in methods of securing the data of Health
Board statistics in the large cities of this country is
strikingly illustrated in an attempt to secure such
data for this article, thus the condition under dis-
cussion is variously classed under such titles as "coal
gas poisoning," "asphyxia," "illuminating gas pois-
oning," "poisoning by noxious gases," etc. For
example, in the Philadelphia Health Board Annual
Report for 1900, I was surprised to find only
one case under the heading "poisoning by illum-
inating gas," until I unexpectedly discovered in the
same document five more cases under the somewhat
indefinite heading "suffocation by gas." There
were doubtless other cases similarly diagnosed. In
Boston there have been as many as forty-three fatal
cases in a year. In the Baltimore Health Board
report for 1900, eleven cases are recorded under
the title "asphyxia" from gas inhalation and
sixteen more under "noxious gases," presumabh-
illuminating gas in most instances. In Chicago, in
1898, the Health Board reported forty-five deaths
from asphyxia by gas, and there were a few more
probable cases under dubious headings. This inac-
curacy of reports makes impossible any attempt to
secure accurate data upon a large scale. In New
York Citv, in 1901, the Health Board reported ninety-
nine suicidal (forty-two females, fifty-seven males),
and 189 fatal, non-suicidal cases of illuminating gas
poisoning, making the important total of 288. In
Bellevue Hospital alone, during the first three months
of 1904, thirty-two cases were treated, with six deaths.
If the mortality ratio represents a fair average, there
must be little short of 2,000 cases in all occurring
each year in New York City, a number which empha-
sizes the importance of more thorough study of the

*A paper read at the meeting of the Association of
American Physicians, May 10, 1^04.

condition than it often receives. This great prepon-
derance of cases in New York City is readily ex-
plained by the prevalence of cheap gas fixtures and
gas stoves in the tenements, and by the large annual
arrival of ignorant pauper foreigners who have never
used gas or who, through poverty and nostalgia,
become despondent and suicidal.

In 1900 W. Sachs,' in an important monograph,
collected from the entire literature references to 420
articles published up to that date upon illuminating
gas poisoning, to which Alexander Panski^ added six
more, bringing the list up to March 16, 1902. Many
of these articles, however, are reports either of isolated
cases or of purely experimental research. A few
small series of cases have been published, but, in so
far as I am aware, the present series is the most
extensive from which an attempt has been made to
draw comparative clinical deductions.

The chief difficulty in the study of this type of
poisoning lies in the impossibility of estimating the
quantity of gas inhaled and the degree of its dilution,
as well as the duration of the inhalation.

The majority of hospital cases are brought to the
hospital during the early morning hours. An igno-
rant, careless, or drunken person goes to bed at night
in a room in which there is a gas stove or gas jet
with a loose cock or leaky pipe, the danger of which
is unrecognized. Falling into a sleep, made heavy
by fatigue or drunkenness, the patient, without
awakening, becomes gradually asphyxiated, at first
with a well-diluted mixture of gas and air, and later
by almost undiluted gas. As coma deepens, the loud
sterterous breathing of the patient, or the odor of
gas escaping beyond the room, attracts the atten-
tion of some early riser, who gives the alarm and
sends the patient to the hospital. Hence it happens
that a majority of the hospital patients are those
who have been inhaling gas for six or eight hours in
increasing strength, and who have probably already
been in coma for at least four or five hours.

In several instances the careless fiinging of a towel
or coat over the gas-bracket just before the patient
got into bed, caused a reopening of a gas-cock which
had been turned off. Some of the most serious
cases arose in connection with the use of gas stoves,
the pipes of which usually discharge much more gas
than those of single illuminating burners. There
are a few other cases in the series among workmen
who have been suddenly asphyxiated by almost un-
diluted gas, or among those who, with suicidal intent
have deeply inhaled the gas from a tube and have
thus been suddenly overcome by it.

Although, as stated, it is difficult to estimate the
volume of gas inhaled in the series of cases reported,
enough had been taken in almost every instance to
render the patient comatose for at least an hour, if
not much longer, after discovery. The minor effects
of chronic gas poisoning in slight degree, such as
anaemia, vertigo, various forms of indigestion, mus-
cular weakness, etc., will not be dealt with in this
discussion.

Among the ninet}' cases of the series, twelve pa-

MEDICAL RECORD.

[July 9, 1904

tients were definitely known to have attempted
suicide, and there were probably as many more who,
upon recovery, were unwilling to acknowledge it.
This is rendered the more probable from the pre-
ponderance of young women among the patients.
The patients comprise fifty-three females and thirty-
seven males, and their ages ranged from four months
to seventy years.

In most of the cases of this series ordinary illumi-
inating gas was inhaled, containing certain volatile
hydrocarbons, besides from 5 to 10 per cent, of carbon
monoxid, but in some cases water-gas was inhaled,
containing from 20 to 30 per cent, of CO. It has
been shown experimentally that one-tenth of one
per cent, of CO, when inhaled, causes discomfort,
restlessness and dyspncea, and between i and 2 per
cent, may be fatal. It is well known that the gas
forms a relatively stable compound with the
haemoglobin of the blood, thus markedly interfering
with the oxygen-carrying power of the red cor-
puscles, but it also possesses a second, more im-
portant, direct toxic effect upon the central nervous
system of the nature of a narcotic and depressant.
That it causes a displacement of the nascent
oxygen of the red cells, and thereby deprives the
tissues and nerve centers of the body of oxygen, is
not a sufficient explanation of the clinical phenomena
of illuminating gas poisoning. These phenomena,
especially those emanating from the nervous system,
are too complex to be accounted for otherwise than
through some specific toxic influence of the gas itself
upon the central nervous system. Moreover, these
symptoms appear in cases in which there is still a
large percentage of red cells unaffected by CO, and
they often persist long after all CO has left the blood.
For example, in Case 43, the red cells on the sixth
day numbered 5,440,000 and the haemoglobin was
95 per cent., yet the patient died two days later
with apparently normal lungs, as well as normal
blood.

In Case 46, on the eighth day, the red cells num-
bered 5,400,000 and the haemoglobin was 95 per
cent. On the twcnt}'-first day the red cells were
4,944,000 and the haemoglobin was 100 per cent.,
but the fever, leucocytosis (18,200), and a feeble
state still existed. That the haemoglobin at this
date was normal was proved by spectroscopic
examination.

The leucocytosis is a very important symptom.
Most of the cases came under observation before the
value of differential counts was appreciated, and
some of them before even a general leucocyte count
was in vogue, hence I am unable to offer differential
counts. A general count was made in twenty-nine
cases, in all but two of which a considerable increase
above the normal was observed. In eighteen of the
twenty-nine cases a leucocytosis above 18,000 was
determined. Among adults the highest non-fatal
cases registered respectively 44,000, 32,000, and
31,000. In the mild case of an infant of four
months, the count was 52,000, but it is naturally
high in infancy.

It is an interesting fact that in every fatal case in
which a leucocyte count was made, it exceeded
18,000, the two highest counts being each 50,000.

The maximum leucocytosis is usually attained
within the first twenty-four hours, but sometimes
not for forty-eight hours. Afterward it subsides
slowly, and in the more severe cases it persists more
than a week and outlasts the coma and many other
symptoms. A leucocyte count above 18,000 or
20,000 is always a symptom of grave import,
although it does not make the prognosis necessarily
fatal, and even in fatal cases there may be a gradual
s-.ibsdence of the number of white cells, as illustrated

by Case 58, in which the leucocytes on succeeding
days were counted as follows, commencing with the
first: (1) 50,000, (2) 38,500. (3) 14,300, (4) 14,200,
(5) 13,800, (6) 13,800. This patient died on the
sixth day from bronchopneumonia. The following
cases are cited in support of the above statements:
Case 33. — Admission count, 22,000. Six days
later leucocytosis (11,300). yet the coma lasted only
eight hours and the temperature did not rise above
101.5.

C.^sE 46. — Leucocytosis lasted twenty-one days,
during which time the patient remained either
comatose or delirious, and the maximum tempera-
ture was 103° F. The maximum leucocyte count
was 21,800 and the minimum 13,800. The red cells
and haemoglobin percentage, first estimated on the
sixth day, remained normal.

Case 45. — The admission count was 14,600. The
following day it fell to 7,700, and the patient re-
covered.

Case 4. — The admission count was 44,000; two
days later it fell to 15,000; coma lasted only one
day, and the temperature did not exceed 10 1.5.
On the sixth day the patient recovered.

Case 62. — This patient was comatose for only
three hours after the time of first exposure to the gas,
yet the leucocyte count was 14,000. A differential
count showed: polymorphornuclear cells 92.3 per
cent., lymphocytes 3.3 per cent., large mononuclear
cells 4.1 per cent., eosinophiles 0.3 per cent.

Case 31. — The admission count was 13,500; the
following day it rose to 21,200, and the patient died.
in coma on the fourth day.

In explaining the leucocytosis, no doubt some
allowance should be made for the stasis in the
peripheral vessels accompanying cyanosis, but that
this is not the sole cause is demonstrated by the fact
that leucocytosis is observed in mild cases with
vigorous pulse and no cyanosis, and in other cases it
persists after cj'anosis has disappeared. It cer-
tainly does not accompany, as in hemorrhage, a
numerical loss of the red cells, for they remain normal
in number, and, moreover, it often exceeds in degree
the leucocytosis of that condition. It would appear
to be a justifiable conclusion that it is due to some
specific action of the gas, such as may occur in
ptomain poisoning. (In a case of the latter
toxaemia 1 have records of a leucocytosis exceeding
15,000.)

I am indebted to Dr. Herbert S. Carter for an-
analysis of the chlorides and urea of the blood in
five non-fatal cases. According to Halliburton' the
average percentage of chlorides in normal blood is:
sodium chloride 0.27, potassium chloride 0.205;
total chlorides 0.475. In Carter's cases the total
percentage was as follows: (i) 2.5, (2) 1.4, (3) i.oi,
(4) 0.62, (5) 0.57, showing a considerable increase in
several instances.

According to Halliburton, the urea percentage of
normal blood lies between 0.02 and 0.04, whereas in
four of Carter's cases the analyses gave (i) 0.063, (2)
0-057. (3) 0.05 and 0.037 respectively.

The temperature of the body is elevated in almost
all the unconscious cases, and fever lasts from one day
to a week or more, the average duration being about
three days. The temperature does not afford a
definite index of the severity of the case, for there
may be a low temperature with coma, as in Case 6,
in which the temperature did not rise above 100° F.,
although the patient remained unconscious four
hours after being brought to the hospital, or there
may be a high temperature with normal conscious-
ness.

In eight cases there was a preliminary fall before

July 9, 1904]

MEDICAL RECORD.

the rise of temperatvire, as shown in the following
group :

Case 6.— The admission temperature was 97° F.,
but the pulse was 120 and respiration 28. Sub-
sequently the temperature rose to ioo°F., with the
same rate of pulse and respiration.

Case 8, in which the patient's admission record
was temperature, 96.4°F.; pulse, 126; respiration, 30.
In this case the maximum temperature, ioi.5°F.,
was attained on the second day, but the pulse rate
fell to 84, and the respiration to 20. Unconscious-
ness lasted one hour after admission.

In Case 9, although deep coma lasted for ten
hours, the admission record was, temperature, 99°F.;
pulse, 1 50; respiration, 30, and the maximum temper-
ature, attained on the evening of the first day, was
100. 2°F.

Case 18. — The admission temperature was 96. 5° F.,
pulse, 92; respiration, 26. Within six hours the
temperature rose to 101.5° F.; pulse, 140; respira-
tion, 40; and the next morning the temperature
became subnormal.

Case 25 was that of an infant of four months.
The child's nurse was playing with it when she
discovered a strong odor of gas and fell unconscious;
she soon recovered, but the infant continued un-
conscious for about half a da}-. The temperature
remained at 98° F., but the leucocyte count was
52,000, somewhat above the normal for an infant.
Recovery was prompt.

In Case 50 the admission temperature was 96.5°,
and within twenty-four hours it rose to 102.8" F.
After convalescence from the gas poisoning, neuritis
and erysipelas developed.

Case 58. — The admission temperature was 95° F. :
pulse, 98; respiration, 28. During the day, and
following phlebotomy and infusion, the temperature
rose rapidly to 102° F. with the same rate of pulse
and respiration. The temperature continued to rise
for five days when just before death it reached 107° F.
The patient had been exposed all night to the gas,
and remained comatose throughout.

C.\SE 60. — The admission temperature was only
96° F., although the respirations were 40 and the
patient remained five hours in coma before death.
Possibly subnormal initial temperature would be
more often found except for the fact that most
patients have been unconscious for several hours
before discovery. The character of the tempera-
ture varies so much that it is difficult to construct a
typical curve. Thus the maximum, usually attained
on the first day, may be postponed for one or two
days, and a day of normal temperature may in-
tervene between two febrile days. Usually the
temperature is remittent and the subsidence is by
lysis, and in about one-third of the cases, during
convalescence, it becomes subnormal, often falling
as low as 97° or 96° F. In Case 1 5 the temperature,
after reaching 96° F., remained for five days at 97° F.
Case 56. — Illustrates two causes of modification
in temperature which may affect the ordinary toxic
fever of gas-poisoning, namely infusion and pneu-
monia. The patient was admitted with a temper-
ature of 101.8 F., pulse 120. respiration 48. After
a phlebotomy of 8 ozs., and infusion of 1,000 c.c, the
temperature rose to 105.5 F., without alteration
in the rate of pulse or respiration. A chill accom-
panied this elevation of temperature. The latter
fell very rapidly 6.5° F., so that the next morning
the record was 99° F. with pulse and respiration
unchanged. The second day the temperature rose
again to 105° F. and the patient died on the fifth day
of pneumonia.

C.\SE 19. — This patient, an ignorant foreigner,
blew out the gas on retiring, being unfamiliar with

its effects. He had one of the most protracted
fevers of any of the uncomplicated cases recorded
in this series: for nine days the temperature ranged
between 100° and 102° F., for four days more it
reached 100°, and then for two days remained sub-
normal, falling to 97° F. On the first day, a tem-
perature of 102° F., which would have been ap-
parently the limit of toxaemia temperature, was
interrupted by the chill and elevation of temperature
to 108° F., following phlebotomy (8 ozs.) and
infusion (1,000 c.c). The corresponding pulse
was 160, and respiration 56, and leucocytosis 24,300.
Recovery.

The vagaries of temperature are, I think, ex-
plainable on the ground of disturbance in the
normal chemical processes of the body, and cir-
culatory unbalance consequent upon the altered
pulse and respiration, rather than by the assump-
tion of any specific thermogenetic action of the
gas. Other gases and vapors inhaled, like the
anaesthetics, do not produce fever, nor do chemical
poisons as a general rule, unless they give rise to
inflammation, although there are some exceptions
to the latter statement, as. for example, the case of a
child of two years who was admitted to the hospital
within half an hour after accidentally drinking
kerosene. The admission record in this case was:
temperature 102.5° F-. pulse 160, respiration 60.
The following day the temperature was 103° F. and
the patient was drowsy and feeble, but finally
recovered.

The maximum temperature recorded in any of
this series (excepting Case 19) was lo;*" F., and
this case terminated fatally. The maximum record
in any non-fatal case (excepting Case 19) was
104.8° F. (Case 42). The maximum duration of
elevated temperature in any non-complicated case
was twenty-two days.

An interesting case with hyperpyrexia is reported
by William A. Steel of Philadelphia (Philadelphia
Medical Journal, February 16, 1901). The patient
was a girl eight years of age. The temperature rose
rapidly after coma began, and within eight hours
reached 110° F. with heart-beats of 215, the pulse
being imperceptible. After the use of oxj^gen,
hypodermoclysis, a cold plunge and vigorous hypo-
dermic stimulation, the child recovered and was
discharged cured from the hospital on the fifth
day. ijg

The pulse is markedly accelerated, and usually
out of all proportion to the temperature and respira-
tion. It is seldom below 120 nd frequently reaches
136 or 140 during the coma. For example, in Case
24 the pulse rate was 150 while the respiration rate
was 30 and the temperature only 100.2° F. during
coma. The pulse is usually, but not invariably,
much weakened, but remains regular in rhythm.
In other words, the pulse conveys the impression
that the heart is being irritated directly or through
its nerves by some specific form of poison. The
acceleration is certainly not secondary to any
changes in the lungs, for it is observed in many
cases in which the physical examination of the
lungs is entirely negative, as in Case 11. with a pulse
of 142, nor is it due exclusively to the deprivation
of the blood of oxygen, as it exceeds in degree what
would be expected under those circumstances.

The maximum pulse rate observed in any of the
non-fatal cases among adults was 150.

The respiration is accelerated irrespective of the
condition of the lungs. It averages about 30 but
I have records of 12 cases in which it reached 36 or
more, although physical examination of the lungs
was entirely negative. It is apt to be labored or
jerky in type, and with profound coma it may be-

MEDICAL RECORD.

[July 9, 1904

come of Cheyne-Stokes irregularity. This type of
dyspnoea occurring independently of pulmonary
oedema or congestion is necessarily of central
origin, due either to the lack of oxygen at the
medullary center or probably to the direct toxic
irritation there of CO or some other ingredient of
the illuminating gas.

The maximum rate of respiration observed in
any non-fatal case of the series was 62, although it
reached 80 in a fatal case.

In not a few cases artificial respiration was main-
tained for a long time with the effect of prolong-
ing life to recovery. In the two following cases the
respiration rate was extremely slow for some time
after admission:

Case 27. — The patient, designing suicide, took the
tube of a gas stove in her mouth and inhaled the gas
for ten minutes. She was found pulseless, with
respirations of only five per minute. Artificial
respiration was performed, and hypodermic stimu-
lation was given; she became conscious in fifteen
minutes and recovered without fever, although the
pulse reached 120.

"In Case 42 the respiration on admission was only
two or three per minute, and artificial respiration
was maintained for an hour. Phlebotomy and in-
fusion were performed and the breathing improved,
the rate rising to 32. (Recovery.)

Digestive disturbances are observed but are not
severe or characteristic. Constipation is the rule,
and vomiting sometimes occurs, more often in the
mild cases or during convalescence from coma; it
became severe in eight cases of the series.

Extreme dryness of the mouth, and congestion,
redness, and dryness of the pharynx were observed
in many cases.

Several patients experienced excessive perspira-
tion.

The urine presents no special peculiarities. It is
often of high specific gravity, 1,025-1,032, and the
proteid waste is usually somewhat increased. A
heavy deposit of uric acid is common. Albuminuria
was noted in twenty-six cases of the series. In
many the albumin was represented by a mere trace,
in others there was 10 per cent, by volume, with
hyaline and granular casts. As many of these cases
occurred among the alcoholic or those of advanced
years, it is probable that the gas has no direct
influence in producing albuminuria, although it was
observed in an infant of four months.

Casb 55. — In this fatal case, metheemoglobin was
found in the urine on the first day and again on the
third. In several other cases in which it was
searched for, it was not present.

In many cases there was retention of urine
and catheterization was often necessary, even after
consciousness was regained. In the majority of
cases constipation was obstinate, and repeated doses
of cathartics and enemata were reqxiired. In eight
cases there was incontinence of both urine and
faeces, in some instances persisting three or four
days, and outlasting the stage of coma by two or
three days. In a few more cases there was incon-
tinence of urine alone.

The pupils present such varied appearances that
there is nothing typical about them. In fully one-
fourth of the cases they appeared normal and re-
acted normally. In twelve cases they were dis-
tinctly enlarged, sometimes with, sometimes without
reaction to light. In a half dozen cases they were
diminished, twice they were vtnequal in size, and in
two cases there was temporary nystagmus, one pre-
senting also lateral deviation of the eyeballs.

In one or two cases a sensation of fulness and

ringing in the ears was complained of, and in one
instance deafness persisted for a day in one ear.

As stated above, the nerve symptoms are so varied
as to force the conclusion that illuminating gas acts
as a direct poison to the central nervous system,
for they cannot all be accounted for upon the theory
that the gas acts alone by depriving the red blood
corpuscles of their ability to transport oxygen.
These symptoms are: tremors, muscular twitching,
convulsions, rigidity, opisthotonos, anaesthesia, in-
creased reflexes, headache, and coma.

The nerve symptoms vary with the mode of
poisoning. When the patient is awake, and inhales
the gas slowly or well diluted, he experiences head-
ache and vertigo, often accompanied by nausea and
vomiting with muscular prostration. Evidence of
vasomotor paralysis appears in burning sensation
in the skin, especially of the face, and in redness of
the cutaneous surface. Later the lips and extrem-
ities become bluish, although, owing to the peculiar
cherry-red color imparted to the blood by CO, the
ordinary duskiness of extreme cyanosis for some
time may remain absent. It is important to note
that the degree of cyanosis is independent of any
changes in the lungs, such as congestion, oedema,
etc., and is often extreme, while the lungs remain
normal.

The patient meanwhile experiences visual dis-
turbances, confusion of ideas, and becomes drowsy,
perhaps delirious, anaesthetic, and finally comatose.

In cases in which the patient is poisoned while
asleep or under the influence of alcohol, or in cases
in which a large quantity of the concentrated gas is
at once inhaled, the preliminary nervous phenomena
above mentioned are absent, and the patient passes
at once into coma without wakening. The coma,
which is always profound, is usually accompanied by
loud stertorous breathing, and sometimes by dilated
pupils, and involuntary evacuation of faeces and
urine. In some cases, after hours of unconscious-
ness, the patient may be partially aroused to take
nourishment only to relapse again. The coma may
last from half an hour to many days, and it is usually
accompanied, as stated above, by elevation of body
temperature and a rapid feeble pulse, but there are
afebrile cases of coma, as there are cases in which it
is the chief and almost the only symptom. In
Hewetson's case the coma lasted nine days and was
fatal. In Case 46 it lasted ten days.

As the patient slowly regains consciousness, he
may suffer for 'days from mental weakness, dulness,
and confusion with loss of memorj'. Paresis or
spasm of the extremities may persist for several
days after coma with muscular weakness, but in the
majority of cases complete recovery is fairly prompt
without sequelae.

A large number of cases have been reported in
recent years in which there were interesting sj^mp-
toms referable to the brain, cord and peripheral
nerves, symptoms which can be well explained after a
review of the reported autopsies which follow (p. 45) :

Bruneau' reported a case of hemepligia following
gas poisoning. Frinkelstein," one of dementia , and A.
Scott,' one of acute mania with recover^', after ten
days. Zeiler' reported a case of leptomeningitis
serosa. Bruns' reported a case of disseminated
encephalomyelitis, and Alexander Panski,'" another
in which the patient was ill for months with paralysis
of the legs and arms, sensory and speech disturb-
ances, anasmia and mental weakness. Becker" re-
ported a case with multiple sclerosis. Cases with
multiple neuritis have been reported by Glynn,"
Meczkowski" (three cases), Sko-nTOuski," Brugman
and Gruzewski" (six cases), and others.

July 9, 1904]

MEDICAL RECORD.

The only occasional sequelae apart from those
above described referable to the nervous system, are
bronchitis, bronchopneumonia, and lobar pneumo-
nia. Small mentions diabetes as a possible sequel ;
it was not noted in any of the cases of my series.
Pleurisy was observed once. Tuberculous patients
did not appear to suffer more than those with
normal lungs.

The assertion is made by Small (XX Century Prac-
tice of Medicine, Vol. Ill, p. 589) that the chance of
recovery lessens with the duration of exposure to the
gas, and that after eight hours of coma there is very
little chance of recovery, j-et this is by no means an
infallible rule — for example, Hewetson reported, in
the Johns Hopkins Hospital Bulletin for 1893, the
case of a man who was exposed for the very brief
period of three minutes to the inhalation of gas in
an open trench. On immediate removal he was
insensible; coma with repeated convulsions lasted
for nine days when the man died. This case is also
opposed to another assertion of Small (loc. cit., p.
588) that when the onset of coma is sudden, it is
less likely to be either profound or prolonged. It
does not appear from my cases that the mode of
onset of coma is of much prognostic significance.
The following cases are cited in illustration;

C.\SE 3. — Male. German, forty-five years old;
became despondent through loss of work and, having
complained all day of headache, put an open gas
pipe in his mouth, and was found unconscious a few
minutes after, by his wife. In the hospital he
exhibited profound coma, a feeble, irregular pulse,
and a chest full of large sonorous moist rales.
Respiration was of Cheyne-Stokes type, and the
exhaled breath smelled strongly of gas for twelve
hours. The eTacuations of urine and faces were
involuntary. The chest was cupped, phlebotomy
was performed ( 3 viii) followed hy infusion (c.c.
1. 000). Slight improvement resulted, but profound
coma persisted for four days, when the patient could
be aroused to take nourishment. His maximum
temperature was only 100.5"; pulse, 104; respira-
tion, 24, and leucocytes, 10,400. On the eleventh
day the patient was discharged cured, although the
persistence of melancholia should remind one that in
suicidal cases, melancholia during convalescence
might be mistaken for a remaining symptom of
poisoning.

This case is interesting on the following grounds:
(a) The sudden onset of profound coma; (6) the
predominance of coma over all other symptoms,
notably the nearly normal pulse, respiration, and
temperature ; (c) the final recovery after four days of
deep coma.

C.\SEs 43, 44, 45, and 46 belonged to a series of
five patients all sleeping in one room into which
water-gas, containing 20 per cent, of carbon monoxid.
escaped for about ten hours. All were equally
exposed: one died after eight days, two recovered in
four and five days respectively, and one remained
either comatose or delirious and stupid for three
weeks, with a continued fever, but without pneu-
monia; he was finally taken home, when nearly
well. (The fifth patient was not brought to the
hospital.)

E. H. Hartley states (Wood's "Reference Hand-
book of the Medical Sciences," Vol. II, p. 215) that
" when entire unconsciousness has occurred recovery-
is very unusual." This is, to say the least, a pes-
simistic view, for of the 90 cases of this series in
which coma was profound 73 resulted in recovery.
In 39, or more than one-half of the non-fatal cases,
coma lasted one day or longer, and in 12 more it
lasted half a day (12 hours). Among the longest
non-fatal coma records are the following: i case of

10 days' duration, i of 4 days; 4 of 3 days, and 4 of 2
days.

Rigors may be present, but more common are
general muscular tremors and twitching or spasm,
which latter may finally result in violent con-
vulsive seizures and opisthotonos. Repeated con-
vulsions have been known to last for days. In
Hewetson's case they persisted for nine days;
in some of my cases for three or four days. In
eight cases they were very severe. One patient
had convulsions on the third day for the first
time, but she gave a history of epilepsy, and
they were apparently of that origin. She recovered.

Rigidity of a part, or of all of the skeletal muscles,
was_,very persistent in a half dozen cases, and in one
it lasted in some degree for three weeks, and was
often accompanied by twitching or convulsions.
(Recovery). The major reflexes present consider-
able variation. In many cases they were normal,
and when altered, in about equal number they
were increased or diminished. During conval-
escence patients often complain of stiffness of the
muscles and sometimes appear dazed when first
attempting to walk.

A patient of Broadbent's (British Medical Journal.
May 13, 1903) improved for ten days, when rapid
muscular atrophy ensued, and the asthenia cul-
minated in death on the nineteenth day.

Phlebotomy, followed by venous infusion of
normal salt solution, should be performed in every
case in which the patient is unconscious and the
pulse is vigorous. Infusion alone should be per-
formed in every unconscious case in which the
pulse is too feeble to justify phlebotomy. If these
operations are done at all they should be thorough.
It is better to withdraw 15 or 18 ounces of blood
than 8 or 10 whenever the pulse strength permits,
and at least 1500 c.c. of saline solution should be in-
fused. The latter process may be repeated upon
the opposite arm, or hypodermoclysis and saline
enemata ma}^ be given. The objection some-
times raised against saline infusion, that it may
produce pulmonary oedema, is not sustained by
the evidence of the series of 41 cases in which it was
employed, for in no one of them did it give rise to
the physical signs or the post-mortem finding of
cedema of the lungs, but, on the contrary, often
relieved this condition when already present.
Whether the phlebotomy and infusion act by
removing a small portion of the poison, by diluting
the blood, affecting the vascular pressure, by the
influence of the salt infused, by stimulating the
formation of new red blood cells, or in some other
manner, the clinical fact remains that these
measures are beneficial. They do not immediately
restore consciousness, but in the bedside notes
of the cases herein reported it is almost invariably
stated that immediately after infusion the pulse
grew stronger, respiration was of better character,
muscular twitching disappeared, rigidity lessened,
and the general condition of the patient improved.
Of course there are many cases in which a very large
dose of the gas renders all curative efforts futile, but
in a considerable proportion the improvement which
follows phlebotomy and infusion ultimately results
in recovery.

Pathological Findings. — In the succeeding twelve
cases, in which autopsies were performed, I shall
merely quote the records in so far as they concern
the heart, lungs, and brain, as nothing distinctive
was observed in the kidneys or any other organs.
For these records I am indebted to the pathologists
of the Presb\i:erian Hospital, and (for one case) to
Dr. W. J. Elser.

C.\sE 54. — Heart muscle pale and flabby; left

MEDICAL RECORD.

[July 9, 1904

pleura adherent-to thorax throughout ; lungs on sec-
tion both show congestion and oedema throughout;
brain appears normal.

Case 86. — Heart presents lesions of chronic endo-
carditis and myocarditis; the mitral valve is irreg-
ularly thickened, and there are numerous calcareous
vegetations on the aortic valve; lungs pale but
otherwise normal; brain, a calcareous embolus is
found lodged in the internal carotid artery, at the
origin of the middle and anterior cerebral arteries.
The lodgpnent of this embolus explains an attack of
partial hagmiplegia which the patient had three
months before death, and did not appear to be in
any manner connected with the cause of death; the
brain otherwise appeared normal.

C.vsE 78. — Heart presents fibrous patches on the
endocardium and fatty degeneration of the papillary
muscles; lungs, the right lower lobe of the lung is
congested and the left lung is oedematous anteriorly;
areas of bronchopneumonia involve the right upper
lobe and posterior part of the left lower lobe; the
brain exhibits atheromatous nodules in the left
middle cerebral arterj', and congestion of the vessels
of the pia, corpus callosum'and corpus striatum.

Case 80. — Heart soft and .flabby, but not dilated,
filled with fluid and clotted blood; lungs are both
slightly oedematous, otherwise normal; brain, evi-
dence of chronic meningitis is present; the dura
mater is adherent to the calvareum, and both
meninges and brain substance are much congested;
the lateral ventricles contain a small quantity of
bloody serum.

Case 55. — Heart normal; lungs: left pleura pre-
sents patches of fibrous thickening near the base of
the lung, and a few petechias over the posterior part
of the left upper lobe, the latter is oedematous and
congested; the left lower lobe is dark red and its
posterior portion is atelectatic; the right pleura is
here and there adherent, the right lung is empha-
sematous anteriorly, but posteriorly it is congested
and oedematous, with areas of partial atelectasis;
the brain substance, arachnoid and pia are all mod
erately congested.

C.\sE 56. — Heart muscle and pericardium are of a
dark reddish or purple hue; the heart is otherwise
normal; lungs: the left upper lobe of the lung is
tuberculous, the left lower lobe is congested; the
right lung shows areas of emphysema, congestion
and bronchopneumonia; the brain substance and
arachnoid are congested.

Case 57. — Heart normal, excepting slight
atheroma of the coronary arteries; lungs: the entire
pleura is everywhere adherent, and the left upper
lobe of the lung presents a chronic miliarv tuber-
culosis; miliary tubercles are also scattered through-
out the right lung; congestion and oedema are
absent; brain not examined.

Case 58. — Heart muscle flabby, but the organ is
otherwise normal; the right pleura is somewhat
adherent, the bmgs are normal ; brain not examined.
Case 59. — Heart normal; pericardium dry, but
non-adherent; lungs: few petechias on entire pleura;
posterior portion of left upper lobe of the lung is
dark and somewhat atelectatic, right upper lobe is
congested posteriorly, emphysematous anteriorly,
right lower lobe somewhat atelectatic posteriorly;
trachea and larynx are deeply congested; the brain
is much congested throughout.

Case 85. — The heart muscle is pale and flabby, the
left ventricle is slightly dilated; the lungs are both
deeply congested, and show slight emphysema
anteriorly; the pleura is adherent over the right
upper lobe; brain not examined.

Case 60. — Heart shows advanced stage of chronic
endocarditis with calcareous deposit in and vegeta-

tions upon the aortic cusps, a thickened mitral valve
and retracted chordae tendineae; the heart muscle
is pale and hypertrophied ; the lungs are congested
and oedematous and the pleura is adherent over the
right upper lobe ; the brain tissue appears normal
but the cerebral vessels are highly atheromatous.

Case 61. The heart is slightly hypertrophied and
filled with partially clotted dark red blood. The
myocardium is of a pale red, somewhat cloudy ap-
pearance; in the coronary vessels and aortic arch
is a moderate grade of atheroma; the valves are
normal. The lungs present a moderate grade of
congestion and oedema, and in the lower lobes are
foci of aspiration pneumonia; the bronchi are con-
gested and contain an abundant serous exudate;
in the pleurae on both sides are about 100 c.c. of
clear serous fluid. The brain substance is soft and
oedematous, the convolutions are flattened and the
meninges congested; the ventricles contain much
fluid; the anterior internal portion of the left ven-
tricular nucleus, and the adjoining portion of the
internal capsule exhibit an area of softeningabout
three-quarters of an inch in diameter, which con-
tains a number of minute capillary hemorrhages;
the basilar vessels are normal.

[The notes of this autopsy were furnished by Dr.
William J. Esler, from the clinic of Dr. G. L. Pea-
body, at the New York Hospital.]

It is of some interest to note that in no one of these
twelve fatal cases was there entire absence of some
serious chronic lesion in heart, lungs, or brain,
despite the fact that many of the patients were
young. Thus chronic endocarditis, myocarditis,
tuberculosis, pleuritic adhesions, atheroma, chronic
meningitis, etc., testify to the ill health and lowered
vitality of a class of patients whom privation and
physical suffering may have driven to suicide, or
whom ignorance, stupidity, or alcoholism has led to
fatal poisoning. The important conclusion seems
justified that many of these patients might have
survived the gas intoxication, had not either their
respirator}^ circulatory, or nervous mechanisms been
already seriously undermined.

The Heart. — Among the twelve autopsies, in three
the heart was normal, in three it is described as
"pale and flabby," and in six there was evidence of
either chronic endocarditis, myocarditis, or atheroma
of the coronary vessels. Hence there is no constant
appearance of the heart in gas poisoning. If this
toxic agent caused death bj' direct paralysis of the
heart, it might be expected to be uniformly pale
and flabby and perhaps dilated, but the few cases in
which these occurrences were noted arc offset by
others in which it appeared normal, or (as in Case
56) of a dark red color.

The Lungs. — It was a surprise to the writer that
bronchopneumonia, or other definite pulmonary
lesion, is not more eonstantly an outcome of fatal gas
poisoning, but in only three of the twelve autopsies
was bronchopneumonia observed. I have seen it in
one other private case in which it followed complete
recovery from the gas intoxication and ultimately
proved fatal. Two other cases of this series pre-
sented normal lungs, and a third, lungs which were
without congestion or oedema, having only a few
miliary tubercles, hence it maj' be asserted that
death from illuminating gas is not invariably due, if
it ever is. to direct irritant action upon the lungs or
bronchi after the manner of smoke or toxic vapors.
The conditions which might be attributed to such
action may be described as functional disturbances
rather than organic changes, such are: (i) Conges-
tion, complete (one case); (2) congestion and
oedema, complete (three cases); congestion and

July 9, 1904]

MEDICAL RECORD.

cedema in partial areas (five cases), in all eight cases;
(3) atelectasis, partial (two cases); (4) emphysema,
compensatory and partial (four cases). These four
different conditions were found in varying degree
and association in nine of the twelve cases examined,
yet it is well known that all these appearances are
common in the lungs of those dying slowly from
profound toxic influences affecting the blood, the
circulation or the central nervous system, without
reference to any specific pulmonary irritation what-
ever, and such would appear to be the fact in il-
luminating gas poisoning.

The Brain. — Of the nine cases in which the brain
was examined, six presented marked congestion of
the brain substance, pia and arachnoid; in one of
these cases, however, there was evidence of a chronic
meningitis; in the three remaining cases the brain
and its membranes seemed normal. It would thus
appear that cerebral congestion is a common result
of poisoning from illuminating gas, occurring in the
series of autopsies cited, six times out of nine. To
what extent this may be a cause of death is difficult
to determine, but there can be little doubt that it is
often a contributing factor, although not invariably
present. In three of the cases there were marked
changes in the corpus callosum, corpus striatum or
ventricles, consisting of such conditions as softening,
congestion, and hemorrhages.

These appearances, which have also been reported
by other writers, are of the greatest interest. Some
years ago Klebs pointed out the fact that carbonic
oxide poisoning is capable of producing enormous
distention of the cerebral arteries, and in 1893
Alexander Kolisko" referred to this distention of the
central terminal branches of the anterior cerebral
artery as the seat of thrombosis following distention,
and giving rise to the softening of the internal
capsule, and especially of the lenticular nucleus,
which has been often observed. He states that he
has seen several such cases resulting from CO
poisoning, and refers to two more observed by
Polcher. Another interesting case of softening of
the internal capsule and lenticular nucleus was re-
ported by Broadbent," also in 1893. Schaeffer" has
reported two fatal cases in which he found softening
of the brain, cord, and peripheral nerves.

Von Solder" reported the case of a man, forty-one
years of age, who died four months after gas inhala-
tion. At autopsy were found hyaline and fatty
degeneration of the skeletal muscles, atrophy of
peripheral nerves, and degeneration of the anterior
horns in the cervical and dorsal cord. J. W.
Runeberg'" reported two fatal cases with extensive
softening in the lenticular nucleus.

Summary. — From a study of the foregoing 'cases
the following conclusions regarding comatose cases
of illuminating gas poisoning may be drawn:

1. Leucocytosis is both high and persistent, rising
in many cases above 18,000, and in a few fatal cases
as high as 50,000. A differential leucocyte count
shows preponderance of the polymorphonuclear
cells. A high degree of leucocytosis is a very un-
favorable prognostic symptom.

2. Elevation of temperature is observed in nearly
all cases. The fever is usually moderate and of very
irregular type. In many cases a subnormal temper-
ature precedes the elevation, and it is often observed
also in convalescence. The pulse is disproportion-
ately rapid, as compared with the temperature.

3. The nervous symptoms are both varied and
inconstant. Convulsions occur in about 7 per cent,
of all cases and muscular rigidity in a slightly larger
proportion. The reflexes and pupil symptoms show
great variability. The coma bears no definite re-
lation to the intensity or duration of the fever.

Coma lasting four or five days is not invariably
fatal. In the series of ninety comatose cases only
seventeen cases, or 18.8 per cent., were fatal.

4. The results of combined phlebotomy and saline
infusion justify the prompt and thorough employ-
ment of these meastires.

5. Pneumonia is an infrequent complication, and
in a large percentage of fatal cases the cause of
death may be referred to cerebral lesions, such as
congestion of the meninges and brain substance,
hemorrhage of the cerebral capillaries, or hemor-
rhage into and softening of the internal capsule,
lenticular nucleus, and adjacent structures.

REFERENCES.

1. Die Kohlenoxydvergiftung, etc., 1900.

2. Neurologisches Centralblatt, 1902, No. 6, S. 242..

3. Textbook of Chem. Physiol, and Pathol., p. 61.

4. Loc. cit., p. 251.

5. "Thdse," Paris, 1893.

6. "Jahrbxich fur Psychiatrie," 1896.

7. Lancet, 3778.

8. "Inaugural Dissertation," 1897.

9. "Encyklopadisches Jahrbuch der gesammte Heil-
kunde, Bd vi, 1896.

10. Neurologisches Centralblatt. 1902, No. 6, S. 242.

11. Deutsche medizinische W'ochenschrijt, 1893.

12. British Medical Journal, 1895.

13. Gasetta Lekarska, 1899, Nos. 48 and 49.

14. Fortschritte der Medtzin, igoi. No. 18.

15. Kronika Lekarska, 1897, No. 4.

16. Wiener klinische Wochenschrijt, 1893, Bd. vi., No.
1 1, p. 192.

17. British j\Iedical Journal. 1893, p. 1004.

18. Deutsche medizinische Wochenschrijt, 1903, Bd. cc.
ig. "Jahrbuch fiir Psychiatrie," 1902, Bd.xxii, p. 287.
20. " Abhandlungen der finnlandische Gesellschaf t der

Aerzte," Bd. xliv.

34 E.\ST Thirty-first Street.

THE DIAGNOSIS OF TYPHOID PERFORA-
TION AND ITS TREATMENT BY OPERA-
TION.*

By CHARLES A. ELSBERG, M.D..

NEW YORK.
ADJUNCT ATTENDING SURGEON TO THE MT. SINAI HOSPITAL. NEW YORK.

It is now generally recognized that — in spite of the
fact that an occasional patient will ecover without
surgical interference — operative treatment is indi-
cated in every case of perforation of the intestine in
the course of typhoid fever as soon as the diagnosis
has been made. The main questions that confront
the medical man are (i) on what can we base the
diagnosis of perforation and the indications for
operation, and (2) in what cases are we justified in
recommending surgical interference when the diag-
nosis is still in doubt. Operative interference for
suspicious symptoms is a course that has been,
declared justifiable by most writers on this subject,
among whom may be mentioned Finney,' Cushing,"
Herringham and Bowlby,' Shattuck, Warren and
Cobb,' and many others. Inasmuch as the dangers
from a small exploratory incision are much smaller
than those of a perforation of the intestine, this

*Read at the meeting of the Surgical Section of the
New York Academy of Medicine. This^ paper is based-
upon four cases of perforation of the intestine in the-
course of typhoid fever that the writer has operated
upon in the Second Surgical Service at Mt. Sinai
Hospital (Dr. Howard Lilienthal, Attending Surgeon),
and upon the occasional observation of eleven others
which were operated upon by others of the sur-
gical staff of the hospital during the past three years. Of
these fifteen cases, five were operated upon in the First
Surgical Service of Dr. A. G. Gerster during 1901 and
1902, and have been already published in the Mt. Sinai
Hospital Reports for those years; ten were operated upon
in the Second Surgical Service from 1901 to 1903, The cases
that occurred in 1901-1902 are published in the annual
hospital reports for those years : those from the year
1903 have not yet appeared in print, and will form part
of a report on the surgery of the intestines in the Second
Surgical Service of Dr. Lilienthal for the past four years,
which will be published elsewhere.

MEDICAL RECORD.

[July 9. 1904

course would certainh' seem the correct one. .-Vs I
shall mention later, however, delay is advisable in
some of the cases.

There has been much discussion as to what is
meant by the term "symptoms of perforation," and
there is still little unanimity of opinion on this
question. The attempt to distinguish between the
symptoms of perforation and those of the resulting
peritonitis is in very many cases impossible. The
only symptoms of perforation, per se, that I can
conceive of are, perhaps, sudden abdominal pain
and the presence of free gas in the abdominal cavity.
Sudden abdominal pain occurs fairly often during
the course of typhoid fever, and localized pain and
distention of the abdomen are verj' frequent in this
disease, as has been ably shown by McCrae.' The
presence of free .gas in the peritoneal cavity — if it
can be clearly demonstrated — is almost pathogno-
monic of perforation. Unfortunately, however, it
is often difficult, if not impossible, to determine with
certainty that the gas in the abdominal cavity is
free, and in the second place, in many cases of per-
foration of the intestine there is no free gas. In the
large majority of cases the diagnosis of perforation
is made from the symptoms of an affection of the
peritoneum which has been caused by the perfora-
tion and not from any symptoms concomitant with
and caused by the perforative process. This is the
view now adopted by Osier.'

By this I do not mean to say that there is
not anj'thing characteristic in the onset, and more
especially in the symptoms of the peritonitis, but
that, in the large majority of instances, we are really
describing the early symptoms of peritonitis due to
the perforation, rather than the symptoms of the
perforation itself. In what follows, however, the
term symptoms of perforation will be used for the
sake of simplicity of expression, instead of the
longer term symptoms of peritonitis due to a per-
foration.

I. Some Diagnostic Features of Typhoid Perfora-
tion. — It is always important to obtain from the
physician in attendance data as to the amount of
tympanites, pain, tenderness, etc., that the case
presented during the entire course of the typhoid
fever. We have to learn from the internist regard-
ing the appearance and changes in the symptoms
and signs from the beginning of the symptoms of
perforation. In the cases on which this paper is
based, there was usually the histor}'- of the patients
having suddenly complained of abdominal pain, or
of the more or less sudden appearance of signs of
increase of the existing pain and tenderness.
Thereafter a number of signs and symptoms ap-
peared and progressed until the diagnosis of in-
testinal perforation could be made with certainty.
At this time the patients had more or less increase
in the pulse and respiration, some were in collapse,
others not so, the abdomen was tender, distended,
and rigid to a varying degree, there were the signs
of free fluid and sometimes of free gas in the peri-
toneal cavity. Collapse does not occur as often as
one would expect in these patients, and it would
seem as if the degree of collapse was dependent more
upon the virulence of the peritoneal infection than
upon the size of the perforation or the amount of
intestinal contents that has escaped. Thus of the
fifteen cases that form the basis of this paper, only
four were in collapse when the diagnosis of perfora-
tion was considered sufficiently certain to indicate
operative interference. In almost all of the pa-
tients the general condition became steadily worse
up to the time of operation, in most of them the
condition was very poor, but only four were in utter
collapse at the time of the laparotomy.

The distention of the abdomen varied much in the
fifteen cases. In six cases the distention was very
marked, in eight the distention was only slight or
moderate, in one case there was no distention. It is
rare that the abdominal distention is due to the
escape of a large quantity of gas from the perforated
bowel. The gas is usually within the intestine, very
often the amount of abdominal distention is directly
proportional to the degree and extent of the peri-
toneal inflammation.

Diminution in the area of liver dulness has been a
valuable diagnostic aid to us in our cases. There
was a greater or lesser diminution in the area of liver
dulness in fourteen of the fifteen patients. In a
considerable number of cases this diminution is due
more to the intestinal distention than to the presence
of free gas in the peritoneal cavity. A distended
transverse colon or small intestine may get in front
of the liver or rotate it on its transverse axis, and in
that way cause a diminution in the area of normal
liver dulness. Hence the value of attempting to
percuss out the colon very carefully and of knowing
when the patient's bowels have last moved and what
amount of flatus was passed at that time.

Abdominal pain and tenderness are usually most
marked on the right side of the abdomen, although
the entire abdomen is often tender in these patients.
In six cases of those on which this paper is based,
all parts of the abdomen were equally tender; in
seven the tenderness was most marked on the right
side and lower part of the abdomen ; in two cases the
greatest amount of tenderness was in the left iliac
region.

In sixteen patients there were the signs of free
fluid in the abdomen — movable dulness in the flanks
or fluid wave or both.

Although the normal area of liver dulness was
considerably diminished in fourteen patients, as has
been already mentioned, free gas could be demon-
strated in only five of these. The presence of mov-
able tympany in the flanks with concomitant changes
in the area of liver dulness is characteristic of free
gas in the abdominal cavity. The patients are
usually examined for the evidences of free gas by
turning them first on one side and then on the other
and percussing both flanks in these positions. It
is advisable to move these patients as little as pos-
sible, however, and a verj- thorough examination for
free gas is therefore often not made. I have found
it a very useful and valuable expedient, when exam-
ining for free gas, to have the headend of the patient's
bed raised up very high by an orderly and then to
percuss the upper and lower parts of the abdomen
very carefully ; then to have the head end of the bed
lowered and the foot end raised and then to percuss
the abdomen again, and to observe the changes that
have taken place. I have found the method a very
useful one for the demonstration of free gas in the
peritoneal cavity, without moving the patient from
his dorsal position.

The temperature changes in the cases did not seem
to present anything characteristic, the temperature
was sometimes high and at other times low when the
first symptoms referable to the peritoneum were
noted.

In about one-half of the cases there was a leuco-
cytosis of between 11.000 and iS.ooo. in the other
patients there were less than 8.000 white cells to the
cubic millimeter. Regarding the value of leuco-
cytosis.we have come to the same conclusion as many
other recent writers — that the leucocytosis has but a
limited value. The presence of a leucocytosis can
be used only with circumspection as a diagnostic
symptom, while its absence does not at all exclude
the possibility of a perforation.

July 9, 1904]

MEDICAL RECORD.

II. The Indications for Operative hitcrfcrevce. —
In most of the cases referred to in this paper, the
diagnosis of perforation of the bowel could be made
with almost certainty within four to twelve hours
from the appearance of the first suspicious symptom.
As most of the patients were transferred to the
surgical side of the hospital from the medical side,
the surgeon was asked to see the cases at a very early
stage, but there was often considerable delay before
permission for the surgical interference could be
obtained. The diagnosis was usually first made by
the house staff of the hospital, who were on the spot
to watch the symptoms from their beginning, and
much credit should be given these gentlemen for the
care with which they studied the cases. During the
past three years not a single patient has been oper-
ated upon at our hospital for typhoid perforation in
which the perforation was not present. One case in
which all the symptoms and signs which are con-
sidered characteristic of perforation were present, and
in which permission for the operation was refused,
recovered without operative interference ; two pa-
tients died without operative interference, as in
both the condition was so bad that surgical inter-
ference of anj' kind was considered contraindicated.
If perforation of the bowel in the course of typhoid
fever is considered a surgical complication — and
there is very little doubt that it should be consid-
ered so — then immediate surgical interference should
follow as soon as the diagnosis has been made.
These patients bear the operative interference re-
markably well if only the manipulations are rapidly
done; and one is soon convinced of the correctness
of the statement made by Gushing' that the "diag-
nosis once having been made, nothing short of a
moribund condition of the patient is a contraindica-
tion to immediate operation."

In the cases in which the diagnosis is probable,
especialljr if the general condition of the patient is
becoming steadily worse, it is advisable to make a
small exploratory incision. The operation can be
completed in less than ten minutes, and, if the peri-
toneal cavity should be found normal, the abdomen
can be quickly closed again, and the patient be sent
back to his bed with a good expectation that his
general condition will be little or not at all made
worse by the operation.

It is more difficult, however, to determine if an
operation should be done when the symptoms make
one suspicious that a perforation may have taken
place, but the symptoms are not clear. Of these
cases, a number really have a perforation, and in
them a policy of delay would not be the one in the
best interests of the patient. From our experience
with typhoid perforation during the last three years
we have been forced to conclude that when the
symptoms have been of at least twelve hours' dura-
tion and the signs and symptoms point more to a
perforation than to anything else, especially if the
patient's general condition is growing steadily worse,
the operation is a justifiable one.

It need hardly be mentioned that if the signs of
peritonitis are sufficiently marked to indicate op-
erative interference, no matter what the diagnosis,
delay would be inexcusable.

If, however, the symptoms have existed for more
than twenty-foiir hours, the patient's general con-
dition has remained good, and the diagnosis is still
in doubt, perhaps because the patient has only come
under observation at this time, the surgeon is justi-
fied in advising a few hours' delay if the case can be
carefully watched. If a case of this kind has a per-
foration, it is probable that the affected loop of
intestine is walled off bj' adhesions from the general
peritoneal cavitv. Delay in these late cases should,

however, only be advised after the most careful con-
sideration of the case from every aspect. If the
diagnosis is fairly sure, it would be just as wrong to
wait for adhesions to form in these cases as in a case
of acute appendicitis. The danger of an ill-timed
delay is very great, and it is better to open an
abdomen in rare instances and to find nothing than
to delay too long where early operation is called
for. With thorough observation and careful in-
dividualization it is probable that mistakes on one
side or the other will be very few.

About six weeks ago a patient was admitted into
the hospital with symptoms of more than twenty-
four hours' standing of perforation of the intestine
in the course of typhoid fever, in which Dr. Lilien-
thal advised delay on account of the good general
condition of the patient, the duration of the symp-
toms, and the lack of certainty of the diagnosis.
Twenty-four hours later, however, the signs of peri-
tonitis became more marked, immediate operation
was done, and a large, well-walled-off abscess
opened. A fecal fistula became established, but
closed after several weeks, and the patient is now
convalescent.

II. Some of the Conditions Found at Operation. —
In ten of the fifteen cases the abdomen contained
seropurulent fluid in considerable quantities, and
there were no adhesions between the coils of in-
testine or, at the most, only a few flakes of fibrin
on the intestines. In all of these cases the operation
was done in less than twenty hours from the be-
ginning of the symptoms of perforation. In five
patients there were adhesions in considerable num-
ber between the coils of gut and the omentum, and
in these cases the perforated loop of intestine was
usually walled off by the adhesions from the re-
mainder of the peritoneal cavity, and there was a
collection of seropurulent fluid or pus in this walled-
off cavity. In these five cases the length of time
between the beginning of the symptoms of perfora-
tion and the operation was 36, 18, 24, 6, and 48
hours, respectively. The foregoing figures show
that adhesions are not verj' frequent in the early
stages of typhoid perforation. Whether this want
of the tendency to form adhesions is due to the low
percentage of the fibrin factors in the blood serum
of these patients, or to something in the intestinal
contents (toxin? typhoid bacillus?) which has an
influence in preventing the formation of adhesions,
it is impossible to say. Many authors have men-
tioned the fact that adhesions are rare in the early
stages of perforative peritonitis in typhoid fever
without attempting to give any -explanation for it.
(Gushing,' McCrae and Mitchell,' Russel,' Fix and
Gaillard," etc.) Sometimes the perforation is
closed by fibrin, or by an adhesion of omentum or
neighboring coil of intestine, but more often it opens
free into the peritoneal cavity, so that when the
perforation is exposed, fecal material is to be seen
to be escaping from it.

In six of the fifteen cases the abdominal cavity
contained free gas, in five of which the free gas was
demonstrable before the operation. As has been
already mentioned, the presence of free gas in the
peritoneal cavity makes the diagnosis certain.

Deep ulcerated Peyer's patches, which have not
yet perforated, can be plainly seen through the
peritoneal coat of the bowel as deep red, round, or
oval areas. If the peritoneum which forms their
base has lost its normal lustre and feels thick and
infiltrated, the ulcers must be considered on the
verge of perforation. In two of my cases and in
several of those operated upon by colleagues at the
hospital, there were suspicious areas of this kind.
Sometimes these suspicious spots are so numerous

MEDICAL RECORD.

[July 9, 1904

that they occupy the greater part of the lower one
to two feet of the ilium with, perhaps, the appendix
vermiformis and part of the caecum and ascending
colon, so that it is almost impossible to suture over
all of them without causing an extensive and too
great a narrowing of the lumen of the bowel. This
condition was present in one of my cases in which I
sewed over only the very worst patches, four in
number, and had the misfortune to lose the patient
from the perforation of still another ulcer. The
post-mortem examination in this case showed that
the lower foot of the ileum was filled with large and
deep ulcers. The ideal method of treatment in these
cases would be the resection of the affected loop of
intestine — a procedure which is, however, too
dangerous, and which would no doubt cause so
much shock that few of the patients would long
survive it.

IV. The Manner in Which the Patients Stand the
Operative Interference. — One would expect that
patients — the most of whom are already exhausted
by their long and severe disease — would bear the
operative interference badly. Fortunately, how-
ever, this is very often not the case, and, if the
operative manipulations are done with rapidity, the
patients seem often to be in better condition at the
end of the laparotomy than they were at its begin-
ning. In some way, the removal of the toxic
material from the peritoneal cavity has an imme-
diate beneficial effect upon the general condition.
This improvement may be due in part to the hot
saline irrigation of the peritoneal cavity, which acts
not only as a cleansing agent but also as a powerful
stimulant — an internal infusion. It may also be
due in part to the morphine which is often given to
the patients just before the operation. It must be
remembered in this connection, however, that the
same methods are usually adopted by us during
operations for other perforative conditions of the
gastrointestinal tract. But in the latter I have
never seen such marked improvement immediately
after the operative interference. Of the writer's
four cases, three were in distinctly better condition
when the operation was concluded than before it
was begun. The same has been the case in many
of the patients operated upon by others at Mt. Sinai
Hospital and in many of the cases reported in the
literature of the subject. In the cases with a fatal
outcome, most of the patients did not die from
shock a few hours after the operation, but they died
a number of days later from the infection of the
peritoneal cavity due to the perforation. Several
patients recovered from the laparotomy but died
after several weeks from their typhoid fever. The
remarkable manner in which a large number of these
patients stand the operative interference has been
already commented upon by a number of writers,
especially by Gushing and Finney of Johns Hopkins.
An important condition for success, as I have just
mentioned, is that the operative manipulations be
rapidljr done, with as little exposure of the intestines
as possible.

V. The Course of the Disease after the Operation. —
As is well known, perforation in typhoid fever occurs
most often during the course of the third to fourth
week of the disease or during a relapse, at a time
when the fever is usually still high. In three of the
patients that I have operated upon, and in several
of the cases operated \ipon by colleagues at our
hospital, there was within twelve to eighteen hours
after the operation a siidden fall of the temperature
to the normal or near the normal, followed later by a
rise, but the regular course of the typhoid tempera-
ture seemed to have been broken. The writer has
gained the impression that such a fall of temperature

during the first twenty-four hours after the opera-
tion has considerable prognostic significance, inas-
much as four of the five patients that recovered had
this drop of temperature. It was present only in
one patient in whom the disease ended fatally, and
that was a case in which the patient died in sudden
collapse from a second perforation (see Case IV at
the end of this article). In this connection it is of
interest that Hutchinson {Philadelphia Medical
Journal, January 17, 1903) gives an account of three
cases in which no perforation was found at operation
and the abdomen had been flushed with saline solu-
tion, in each of which there was a distinct drop in the
temperature for thirty-six hours, after which the
typhoid fever continued its course and the patients
recovered.

In one of my cases the temperature again rose,
due to the appearance of numerous furuncles and
abscesses all over the body; in a second case, after
ten days of normal temperature, the patient had a
severe and prolonged relapse with high tempera-
tures and a very rapid pulse, but he recovered.*

In the patients that recovered, the abdominal
signs disappeared with considerable rapidity; at
the end of twenty-four to forty-eight hours, the
abdomen had become much less distended and ten-
der, and in four to five days practically all of the
abdominal symptoms, except those due to the wound
in the abdominal wall, had disappeared.

Healing was not essentially different from that
after laparotomy for perforative peritonitis from
other causes. The wound in the abdominal wall
should be drained, as otherwise it is very apt to
become infected.

VII. Some Details Regarding the Operative Alatti-
pulations Which Are of Interest.- — Rapidity is a sine
qua von for success in operations for typhoid perfora-
tion. In less than twenty minutes' time it is usually
possible to open the abdomen on the right side, find
the perforation and suture it, examine four to six
feet of the lower ileum, beginning at the ileocascal
junction, suture over any areas that seem to be in
danger of perforating, wash oiit the peritoneal
cavity with hot saline solution, drain the peritoneal
suture line, and close the remainder of the incision
in the abdominal wall by an appropriate suture.
The duration of the operation in the writer's cases
was II, 18, 14, and 23 minutes respectively. The
abdominal incision should preferably be made along
the outer side of the right rectus muscle or through
its fibers, as the lesion will most often be found on
the right side of the abdominal cavity, unless the
physical signs should point to some other part of the
abdomen. The incision should be a liberal one from
the very beginning. As soon as the peritoneal cavity
has been opened, one must look for the caecum and
ileocaecal junction, and when this part of the bowel
has been exposed, pull into the wound the most
prominent loop of small intestine which lies against
it. In a considerable number of the cases, this loop
will be found to be the affected one and the perfora-
tion thus be most quickly found. If there is no one
loop that is particularly prominent, one must begin
the examination of the ileum from the ileocaecal
junction. As soon as the perforated ulcer has been
found, the opening should be closed by a double
layer of Lembert sutures passed in the long axis
of the bowel, so that they will cause a minimum
amount of narrowing of the lumen of the intestine.
If the perforation of the bowel wall is so large or the
infiltration so extensive that simple suture is im-
possible, one of two procedures can be followed —

♦The recoverv of this patient was in no little part due
to the verk- careful watching and treatment of the house
physician, Dr. Kremer.

July 9, 1904]

MEDICAL RECORD.

either a portion of the omentum can be sewed over
the opening, or the affected loop of intestine can be
anchored in the wound by a few sutures, and a fecal
fistula thus established. Escher" has recently recom-
mended that the perforation should never be sutured,
but that the loop of bowel should be anchored in the
abdominal wound and the bowel drained. Escher
claims that the operation can thus be done with
great rapidity, and that the drainage of the bowel
prevents paralytic ileus and exerts a favorable effect
upon the peritonitis. It is preferable, however,
to close the perforation, unless it be too large or the
surrounding bowel wall too much diseased. In the
latter condition the method of Escher is surely
preferable to resection of the bowel.

If there is any doubt that the intestinal sutures
will hold, it might be advisable to keep the loop near
the wound by fi.xing its mesentery or the bowel itself
to the abdominal wall with a few sutures.

Any ulcers that seem to be in danger of per-
forating should be just as carefully sewn over as
the perforated one. If there are a large number
of these dangerous ulcers in the lower ileum, it
is advisable to wall off the affected loop of gut from
the peritoneal cavity by a small gauze packing on
each side of it, and thus guard against the danger to
the peritoneal cavity from a possible later perforation.

Wherever sutures have been applied to the in-
testinal wall, it is a good plan to rub a little iodoform
powder over the suturfe line — through the irritant
qualities of the iodoform the adhesive process is
hastened.

Since the publication of the writer's last paper
on perforation of the intestine in the course of
typhoid fever, he has been led to change his views
on the subject of irrigation of the peritoneal cavity.
Although we have to depend to a great extent upon
the absorptive powers of the peritoneum, absorption
can be hastened and aided by irrigation of the cavity
with isotonic 0.9 per cent, saline solution. Aside
from the fact that by this irrigation considerable
toxic material is removed, it acts also as a powerful
stimulant, and this function of the irrigating solu-
tion should not be underestimated. One has onlj'
to note the immediate improvement in the patient's
condition in a few cases in order to become con-
vinced of its value.

After a thorough irrigation, the smaller the drain
that is inserted into the abdomen the better. It
is now well known that drainage of the general
peritoneal cavity can seldom, if ever, be accom-
plished. It will generally suffice to pass a small
strip of gauze or a cigarette drain do-s\Ti to the suture
line in the intestine or underneath the sutures in
the parietal peritoneum, and then to close the
greater part of the abdominal incision.

In the cases in which the perforation in the wall
of the bowel is walled off from the general peritoneal
cavity by adhesions and lies in the bottom of an
abscess cavity, it is advisable to do nothing more
than to open the abscess and drain it, leaving the
perforation in the wall of the intestine to take care of
itself. The fecal fistula which usually becomes es-
tablished will often close of itself, as it is situated
in the lowermost part of the ileum, otherwise a second
operation maybe necessary later on to close it.

Many writers recommend that operations for
typhoid perforation had best be done under local
ansesthesia. However, the writer would agree
with those who prefer a general anaesthesia. I
believe that a fair-sized dose of morphine, followed
by a light chloroform anaesthesia, is preferable in
most cases. From my experience in abdominal
surgery under local anaesthesia, I have learned
that in most cases the handling of the small intes-
tine and the straining of the- patient while the

abdomen is being washed out with saline solution
contributes more to shock than a light chloroform
anaesthesia, aside from the fact that under general
anaesthesia the necessary manipulations can be
more qiiickly accomplished.

The after-treatment need differ in no way from
that after laparotomy for other conditions, with the
exception that the general feeding miist be that
of a patient with tj'phoid fever.

Case I. — Female, six and a half years of age.
transferred from the service of Dr. Koplik. Per-
foration on lower ileum on thirty-third day of
severe typhoid. Before operation, temperature,
104.4; pulse, 180; respiration, 40. Collapse very
marked. Laparotomy and suture of perforation
sixteen hours after first symptom. Seropurulent
peritonitis, free gas in peritoneal cavity. Duration
of operation, eleven minutes. Convalescence de-
layed by furunculosis and multiple abscesses;
recovery."

Case II. — Male, eighteen years of age, transferred
from the medical service and operated upon Sep-
tember 21, 1903. Perforation in lower ileum in
fifth week of disease. Laparotomy and suture of
perforation and of one area on the verge of per-
foration. Fasces and free gas in peritoneal cavity.
Duration of operation, eighteen minutes. After
ten days of normal temperature, severe relapse
with high temperatures and very rapid pulse;
recovery.

Case III. — Male, nine years of age, admitted to
the hospital and operated upon on August 6, 1903,
in the third week of typhoid fever, with symptoms
of general peritonitis of about twenty hours' stand-
ing. Patient's condition verj- poor, he had to be
infused upon the operating table. Laparotomy
with removal of appendix and suture of perforation
in lower ileum; seropurulent peritonitis. Duration
of operation, fourteen minutes; recovery.

Case IV. — Female, nine years of age, transferred
from the children's service of Dr. Koplik and ope-
rated upon September 30, 1903. Patient in very
poor condition. Perforation in lower ileum on
twenty-seventh day of severe tj-phoid fever. Lapa-
rotomy and suture of perforation about eight hours
after first symptom; suture of three suspicious
areas; fluid and faeces in general peritoneal cavity.
Duration of operation, twenty-three minutes. After
eighteen hours, condition of patient fairly good;
no vomiting, abdomen more soft and not very
tender; pulse 130 and of good quality. At expira-
tion of twenty-second hour, sudden change in con-
dition; collapse, death. The post-jnortem ex-
amination showed that there was a second perfora-
tion between two of the sutured areas; the entire
lower twelve inches of the ileum was filled with nu-
merous large and deep ulcers; large amount of fecal
matter in peritoneal cavity.

REFEREN'CES.

1. Finney, Johns Hopkins Hospital Reports, 1900.

2. Cushiiis;, Annals oj Surgery, May, igoi.

3. Herringham and Bowlby, Medico-Chirurgical Trans-
actions. Vol. LXXX, p. 127.

4. Boston Medical and Snrgical Journal, Vol. CXLII,
No. 26, p. 627.

5. McCrae, Johns Hopldns Hospital Reports, 1903.

6. Osier, "Nothnagel's System," American Edition.

7. Gushing, loc. cit.

8. McCrae and Mitchell, Johns Hopkins Hospital Re-
ports, 1902.

g. Russel, Montreal Medical Journal, 1903, XXXVIII,
pp. 63—70.

I o . Fix and Gaillard,.4 rchives de Medecine et de Pharmacte
Militaires, Paris, 1905, XLI, p 218-230.

11. Escher, Grenzgebieter der Medizin und Chirurgie,
Vol. XI, No. I. , ,

12. This case was reported in detail in the Annals of
Surgery, May, 1903.

Madison Aves-ue .\nd Sixty-third Street.

MEDICAL RECORD.

[July 9. 1904

A METHOD OF SECURING FIXATION AND
HARDENING OF THE CENTRAL NERVOUS
SYSTEM BEFORE THE AUTOPSY.*

By B. ONUF (ONUFROWICZ). M.D.,

'PATHOLOGIST TO THE CRAIG COLONY. SONYEA. N. Y.

Whether the method herein described is new
I do not know. It was new to me and it is cer-
tainly not generally known, otherwise the com-
plaint of the inability to preserve the central
nervous system within a few hours after death,
consequently the impossibilitj^ of studying the
finer strvictural changes in a given case, would
not be heard so often.

The method is comparable in its simplicity to
the egg of Columbus. The procedure consists in
injecting as soon as possible after death a strong
solution (12 per cent.) of formalin, first by lumbar
puncture, then through the foramen magnum. The
former hardens the spinal cord, the latter the brain.
By use of a T branching tube, both injections can
be combined in one act.

The details of the procedure may be varied ac-
cording to necessity and further experience.

My first attempt, which proved surprisingly suc-
cessful, was made with an aspiration needle and
the Dieulafoy syringe.

Since then I have learned to use a Davidson ball
syringe with equal success. It is known that the
pump of the Dieulafoy syringe can be used in two
ways, according to the manner in which it is con-
nected, i.e. either for exhausting the air or for com-
pressing it. In this procedure it is used for com-
pressing the air.

The subjoined illustration shows the manner in
which the apparatus is put together. It is con-
venient for the piirpose to use a bottle with three
mouths. This bottle is filled with the injection
fluid. Mouth C has a rubber stop through the
bore of which passes a glass tube down to the bot-
tom of the vessel. At its upper end this glass tube
is connected with the rubber tube ZZZ, preferably
non-collapsible, to which is attached the aspiration
needle. The latter attachment is by metal con-
tact only, as is the case with many hypodermic
needles which fit the barrel of the syringe by con-
tact only instead of by a thread. Such an arrange-
ment has the advantage of being easily detachable.

Mouth B is closed with a common cork or rubber
stopper. It can be used for refilling the bottle
when the fluid is almost exhausted without dis-
turbing the other arrangements.

Mouth A has a rubber or cork stopper through
the bore of which passes a T-shaped tube with
which, by means of a thick-walled rubber tube RRR

*From the Pathological Laboratory of the Craig Colony
for Epileptics, Sonyea, N. Y. " » -

(preferably non-collapsible), the Dieulafoy syringe is
connected. Stop-cocks of this T-shaped tube has
to be kept open; stop-cock T of the same tube has
to be kept closed. It hardly needs mentioning
that the tube passing through the bore of the stopper
of mouth A must not go down deep enough to reach
the fluid. In other words, the bottle must not be
filled so high as to have this tube immerged in the
fluid.

The Dieulafoy aspiration syringe has two out-
lets, X and Y. If the rubber tube RRR is connected
with outlet X, the action of the pump will exhaust
the air in the bottle. If the rubber tube RRR is
connected with the outlet Y of the pump, the action
of the latter will, on the contrary, compress the air
in the bottle.

The manner of required connection (namely, for
compression) is indicated by arrows on the syringe.
Moreover, a few trials will very soon show whether
the pump is arranged for compression or for ex-
haustion.

After the apparatus has been put together in
working order, one proceeds as follows:

The aspiration needle is detached from tube ZZZ
and is introduced into the dural sac in the same
manner and locality as in lumbar puncture. In
doing so it is advisable to put the corpse into a
sitting or semi-inclined position so as to let
the cerebrospinal fluid accumulate in the
lowest portion of the' dural sac.

A trocaris preferable to a needle because the
latter is apt to become obstructed by fat. There
ma}^ or may not be an escape of fluid from the
needle if the puncture is successful. The real
test of the success lies in the result of the
pumping, i. e. whether, when the pumping is
started, the level of the fluid in the bottle is
lowered.

After the needle, or trocar, has been intro-
duced with apparent success, the pump is put in
action, causing a compression of the air in the
bottle ABC, pressingthe fluid into the glass tube
passing through C, and thence into the rubber
tube ZZ. The pumping is continued until the
fluid spurts out in a continuous stream from tube
ZZ . At this moment , tube ZZ is quickly attached
to the aspiration needle and the pumping is then
continued. If the experiment was successful, the
level of the fluid will now become lowered in the
bottle. In case of doubt a mark designating the
upper level of the fluid will soon show us whether
this level is becoming lower or not. If it does
not sink, this means either that the needle, or
trocar, has not reached the spinal canal, or that
the needle is obstructed by fat and other
material. In such case tube ZZZ has to be
detached and a wire is passed through the
needle. If this is unsuccessful, the needle must be
withdrawn and introduced a second time.

I may here add that my experiment succeeded only
after I had introduced the needle for the third time.
The question now arises how long to continue
pumping. My experience is that, after a time,
the fluid sinks \&xy slowly and the pumping be-
comes very difficult. Moreover, air is heard sizzling
out around the corks or around the tubes passing
through the corks, and from time to time the corks
are forced out of the mouths. This is about the
time to cease, and this forcing out of the corks
serves as a safety valve, preventing, in all proba-
bility, the pressure of the injection fluid on the cord
from becoming so high as to injure the tissues.

The idea is first to fill the entire dural sac with
fluid and after that the whole spinal canal, into which
the fluid will naturally ooze when the dural sac
has become entirely filled.

July 9, 1904]

MEDICAL RECORD.

One next proceeds to harden the brain. The
needle, or the trocar, is introduced into the fourth
ventricle, at least that is the aim. The skull is
palpated to locate approximately the foramen
magnum, then the needle is tentatively introduced
in the neighborhood of the foramen magnum and in
a direction presumably parallel to the floor of the
fourth ventricle. If it strikes bone, it will be rather
easy to say whether such is the occipital bone or
the spinous process of one of the upper cervical
vertebrae. On the whole, it is better at first to
strike too high, i.e. against the occipital bone. In
such case the needle is taken out again and intro-
duced a little lower down. One can thus gradually
feel his way until he strikes just inward of the
dorsal margin of the foramen magnum. The needle
is then pushed deeply enough to enter the fourth
ventricle, not deep enough, of course, to injure the
cerebellum or oblongata. Whether the needle
really needs to enter the fourth ventricle I do not
know. Indeed it seems hardly necessary since the
foramen Magendie gives sufficient means of com-
munication between the ventricle and the surface
of the cerebrum and cerebellum, so that, if only the
subdural or subarachnoid space is entered, the
fluid should have a good chance of being distributed
over the surface of the cerebrum and cerebellum
as well as to the ventricles.

The particulars will have to be learned by ex-
perience. Injurj- to the adjacent parts, cerebelkim
and oblongata, should of course be avoided. In
my case neither of these structures showed any
evidence of injury; but choosing between two evils,
injurj- of the cerebellum would, on the whole, seem
less harmful, special cases excepted, than injury of
the oblongata. By keeping well in the median
line, injury to both the.se parts can probably be pre-
vented. If the needle should enter into the brain
substance, this would soon be shown by the failure
of pressing the fluid in, after the needle has been
reconnected with the pumping apparatus and the
pumping commenced. In case of success, the level
of the fluid in the bottle will soon become visibly
lower. As to the quantity of fluid to be used, I
may say that, in my first attempt, about one-half
pint was introduced into the brain and about four
ounces into the vertebral canal.

Whether it is necessary to use a Dieulafoy as-
piration, or rather compression, syringe for the in-
jection, I cannot tell. As I have mentioned already,
the same results may be obtained with the much
cheaper Davidson syringe or with a similar ball
syringe, in which case the bottle described can be
done away with. Let me also repeat here, that by
the use of a T branching tube, one end of which is
connected with the pumping apparatus, the second
end with the aspiration needle, passing into the
lumbar sac, and the third end, with the needle
passing into the forameg mannum, the two injec-
tors, -i.e. that into the ducal sac of the spinal cord,
and that through the foramen magnum, can be com-
bined in one procedure, thus saving time and equal-
izing the pressure of the fluid.

I shall now relate the results of the injection in our
first case, which was made about one hour after death.
First, however, let me mention that the body was
then placed in the ice-box in usual position, i.e.
lying on the back. This is, of course, the most
common position, but there is a particular reason
for mentioning it, as will be seen later.

The autopsy was made forty-three hours afte^"
death, the body being left meanwhile in the
ice-box. The peculiarity was then noticed that the
fat of the abdominal wall was of an abnormally
firm, waxlike consistency and of a dark, dirtj^

brown-gray color, while that of the thoracic wall
had the usual appearance and consistency. On
opening the abdomen, the fat of the mesentery in
the lower portion of the abdomen was found to have
the same peculiarity as that of the abdominal wall.
I suspected that this was due to the effect of the
formalin.

Further examination showed that a great portion
of the liver also had a peculiar appearance, and here
there was no doubt that such was due to the effect
of the formalin, since the tissue in some parts looked
whitish and was so hard that no other explanation
was possible. I then felt certain that the peculiar
fat referred to was due to the same cause.

First I was at a loss to account for this fact, but it
now seems clear enough. It is natural to assume
that, after the vertebral canal became filled with the
injection fluid, it began to penetrate through the
foramina intervertebralia into the surrounding tis-
sues. It should be added, however, that the lungs,
heart, spleen, pancreas, and kidne3^s showed no for-
malin effects, which is of value to know, as it shows
that the spinal cord and brain may be preliminarily
hardened without diminishing the value of an ordi-
nary autopsy, to be made later on.

As to the effect of the injection on the spinal cord
and brain, it surpassed my most sanguine expecta-
tions. The spinal cord was completel)' hardened in
its entire length and thickness, as shown on a trans-
verse section made through the middle dorsal region
and as shown by its hard consistency through the
entire length.

The brain also was, to all appearance, more or
less hardened throughout. It showed the same
elastic hardness which a brain shows after injection
of a lo-per-cent. solution of formalin into the aorta
(with tying off of the thoracic aorta), as practised by
Drs. Adolf Meyer and Dunlap at the Pathological
Instittite of the New York State Hospitals.
Twenty-four hours after removal of the brain the
Meynert section was performed, i.e. the pallium
(hemispheres) was separated from the rest of the
brain. It was then shown that the formalin had
penetrated everywhere. The hemispheres were
found hardened in their whole thickness. The basal
ganglia were also hardened, although in varying de-
gree — the caudate nucleus less than the thalamus;
but all parts showed the effects of the formalin. An
absolute hardening of all parts could, of course, not
be expected; but the important fact was noticed
that no part showed any post-mortem decomposi-
tion, i.e. softening and putrefaction. Without the
formalin such changes could have been expected
with certainty, in view of the fact that the autopsy
was performed forty-three hours after death, even
although the body was in the ice-box all this time.
However, the most valid proof and most delicate
test of the preserving and fixing value of the
method was given in its influence on the neuroglia.
That this tissue suffers very quickly through post-
mortem disintegration is known to everybody
familiar with it, and if in a given brain the neuroglia
stains well, this is always a proof of early preserva-
tion and flxation of the brain. In the first case in
which the method of preliminary formalin injection
was made one hour after death, and in which the
autopsy was performed forty-three hours after death,
pieces from four different regions, namely, cerebral
cortex, cerebellar cortex, medulla oblongata and
caudate nucleus, were removed twenty-four hours
after the autopsy and subjected to the procedures
required for the Mallory Phosphotungstic-hema-
toxylin neuroglia stain. The stain succeeded very
well in all four regions, but of particular value was
its success in the caudate nucleus which, as men-

MEDICAL RECORD.

[July 9, 1904

tioned above, was softer than the other parts of the
brain, i.e. not so well acted upon by the formalin.
How well it succeeded is seen by the adjoining fig-
ure showing the neuroglia fibers and neuroglia
nuclei of a part of the caudate nucleus. The pene-
trating value of the method is thus very aptly
shown.

The great value of the method needs hardly
to be emphasized. Every neuro-pathologist knows
how important it is to fix and harden the cen-
tral nervous system no later than six hotirs at
the most after death. Here, we have means of
preserving it immediately after death without in-
flicting any mutilation on the body and without
changing the appearance of the intra-thoracic and

Figure showing a portion of the caudate nucleus stained with Mallory's
phosphotunKStic-hematoxylin neuroglia stain. Taken with Leits'
ocular 4 and immersion 1-12 in.

intra-abdominal organs (with the exceptions men-
tioned) through the formalin.

The method has this advantage over the other-
wise excellent method of formalin injection into the
aorta as practised by Drs. Meyer and Dunlap, and
elaborated in such an ingenuous manner by these
gentlemen — it can be applied immediately after
death in cases in which we are doubtful whether an
autopsy will be permitted or not.

It has the further advantage over that method, of
hardening not onh' the brain, but also the spinal
cord; and the result is not inferior to that of their
method.

An additional advantage is the small quantity of
formalin required, one quart at the most being
needed as against the i^ to 3 gallons necessitated in
Meyer's and Dunlap's method; and this advantage
is not to be undervalued in view of the relatively
high price of this drug.

OCCIPITOPOSTERIOR POSITIONS.*

By S. MARX, M.D..

NEW YORK.

When I was requested to open the discussion on
" Occipitoposterior positions." I thought that the
last word had been said on this subject — that
is, so far as the reader is concerned. The question
of the management of occipitoposterior presenta-
tions has resolved itself into one of relative sim-
plicity, not that any particular schematic thera-
peusis will be offered; for schemes in obstetrics,
as well as in other specialties of medicines, often
go wrong, but the experience offered by meeting
many of these cases has allowed me to present
fixed, though hardly dogmatic, views on the sub-
ject before us, for it is the belief that a finality
has been reached with this question, as well as
with many other obstetric questions. To be
forewarned as to this complication is to be fore-
armed. It is far more frequently met than is usually
thought and taught. But it occurs most frequently
as a primary condition and at so early a stage is

*Discussion opened before the Obstetric Section, New
York Academy of Medicine, April 2S, 1904.

certainly not recognized or is not sought for; for
it does not enter the mind of the attendant
that it is possible to have a malposition of a normal
presentation. Of my own personal statistics, I
quote from my case book that in the last one hun-
dred consviltations in midwifery I have come in
contact with twenty-three cases of persistent occipito-
posterior positions. This, of course, does not carry
with it much importance as to the absolute fre-
quency of this complication, for as a consultant it
is most natural to see nothing but complications.
But of more importance is the careful review of the
cases under my personal care, i.e. private cases —
those examined from the onset of labor and in
which there has been an early determination of
the position, before the head has been markedly
influenced. Here I have noted, in one hundred
cases, seventy primarily posterior occiputs, cer-
tainly a larger percentage than I had any idea of;
and we doubt not that if all practitioners took
the necessary care for a careful and early ex-
amination the same high percentage would be
found. For this reason I wish to record the fact
that primary malpositions of the occiput are
present in a much larger number of cases than we
are led to believe. How much higher still the
percentage may be before the advent of labor is
impossible to tell, except by abdominal palpation,
but for reasons elsewhere given I pin my faith
on internal examination, relegating abdominal
palpation to the position to which it belongs — name-
ly, one of absolute unsafety.

And this leads up to the question of diagnosis.
Even without an internal examination, the symp-
toms presented are so characteristic that a presump-
tive diagnosis can very often be readily made, and this
triad of symptoms ought always be associated with
a possible vicious presentation of the occiput, i.e.
early rupture of the membranes, slow nagging and
teasing pains and abnormal slow and futile labors.
Such evidence can always be clinched by a vaginal
examination, or, if the least doubt exists, the in-
troduction of the full hand into the canal. It is
absolutely essential for successful treatment to make
an early and a clear diagnosis not only of position,
but of presentation; and in this I am sorry to say
too little is done, for the average practitioner always
rests satisfied so long as the hard head presents, caring
little or bothering less what area of the fetal head
present. Earlj* recognition and timely interference
is more than half the battle won, for by such means
we can, in an overwhelming majority of cases, change
the case from an almost impossible one to one of
the greatest simplicity, and thus carry it to a suc-
cessful issue. But of the greatest import is still:
What are you going to do in order to cope success-
fully with these cases? It must be remembered
that a firmly flexed head will almost always rotate
spontaneously, and that the first step in the treat-
ment of these cases is to insure a permanent and
marked flexion; and this can be most readily done
by pressing, throughout several pains, the sinciput
against the chest of the child by two fingers, or
the introduction of the full hand in its grasp, flex-
ing the occiput and thus obtaining the same re-
sult. The permanency of this sustained flexion
is assured by using the postural treatment, i.e.
placing the patient in that lateral prone position
corresponding to the position of the occiput. These
minor manipulations done early and carefulh', as
above described, will, in the great majority of cases,
cause the head to rotate with resultant normal and
spontaneous expulsion. It is advisable to under-
take operative measures at a late period ; or,
to be more concise, operate only when there are

July 9. 1904]

MEDICAL RECORD.

present, symptoms to indicate that interference is
warranted, symptoms the interpretation of which
mean exhaustion on the part of the mother or child.
In obstetrics early and uncalled interference is un-
warranted and may lead to disastrous ends, while
working in armed expectancy is often followed by
remarkable and favorable results for mother and
child, if only for the reason that in this complication,
rotation occurs in a large majority late, i.e. when
the head is low down on the pelvic floor. The
secret of success lies in two directions: (i) operate
only in the face of clear indications on the part of
either mother or child ; (2) operate at once when there
is tendency to posterior rotation.

When either of the just mentioned conditions
arise how are we to meet them?

Cassarean section and symphyseotomy are included
for the reason that we presuppose that we are
dealing with a pelvis that is normal, and consequently
these operations are beyond the scope of this paper.
Yet it occasionally may happen that either one of
the just quoted operations might have to be con-
sidered, especially the pubic section, in those rare
cases in which the occiput is absolutely impacted and
no other means can possibly give us a living child.

In quite a few of these cases, the perforator ought
always be the instrument of selection, for it would
be the height of folly and directly against the
interests of the mother to attempt to deliver by
another means than by a craniotomy upon a child
whose life has already been sacrificed or at best
whose vitality is so low that any form of operative
measure would deliver a dying or hopelessly maimed
child. A rule which I strictly adhere to, so far as
circumstances allow, is to elect the perforator in
all those conditions just mentioned, only in the
presence of a child of good vitality I should elect either
forceps or version, and my selection of these methods
is practically sharply defined, i.e. version when the
head is above the brim, forceps when the head is
fixed at or below this point. What I wish to
elucidate in this paper is the absolute value
of the modern axis traction forceps. But I would
preface my remarks by a note of warning. The
modern axis traction is a dangerous instrument for
the inexpert, even as it is absolutely safe in the
hands of one accustomed to its use. It is a forceps
for the expert only; and if by its use bad results
accrue it is not the fault of the forceps, but of the
operator. Its method of application and its
action have been more fully gone into in another
paper and cannot be entered into more fully
here. But one important method of delivery will be
discussed at length, and that is the method which has
given almost uniform success and satisfaction. I
have given it the name of "rotary axis traction,"
for by this manoeuvre we fulfil a compound in-
dication, i.e. axis traction and, at the same time,
artificial rotation. These, as j^ou will readily see,
are particularly applicable to cases of posterior
position of either the vertex or the face. I cannot
improve upon my statements made in a former
article and shall take the liberty of quoting the
following from the same : In many of these cases of
occipitoposterior positions I have succeeded, by the
use of the Tarnier instrument, in rotating the
head anteriorly by simply allowing it, while traction
is being made, to be influenced by the factors
supplied by nature (the resistance offered by the
perineal structures and furthered by the turning
points afforded by the ischial spines, especially
when they are prorninent) to provoke such rotation.
And herein lies the utility of the instrument. It
allows the head to pass uninfluenced through the
pelvic canal, except for the natural influences which
promote rotation; hence the great advantage is the

free mobility of the forceps when applied to the
head. This rotation begins to occur when the head
descends to the pelvic floor, and is instantly evinced
by the behavior of the blades — they begin to rotate
with the head, the movement increasing with ever}''
traction effort, until the forceps has entirely rotated.
When, however, such tendency to rotation does not
occur, the normal mechanism is probably at fault,
and it is then that "rotary axis traction" becomes of
supreme value. The forceps may be applied ac-
cording to the pelvic walls; but an oblique applica-
tion, i.e. to the sides of the child's head, is better.
When in such position, it conforms to one of the
oblique diameters of the pelvis, insures a more certain
grasp, and very materially aids in the success of this
otherwise rather simple manoeuvre. With the right
hand, steady traction is made, and at the same time,
with the left hand, the handles of the forceps are
compelled, or at least influenced, by gentle rotation
to turn in the direction of the presenting part; to
the left in left occipitoposterior cases, to the right in
right posterior ones. This manipulation must be
persisted in, slowly rotating all the time while
making careful and intermittent traction, timing
our measure so that when the head reaches the
pelvic outlet, complete rotation shall have occurred
and the forceps blade shall be found nearly or
entirely inverted. At no time should brute force be
used, but the greatest gentleness exercised at all
times. I have on a number of occasions tried
forcible rotation by the ordinary forceps, and have
succeeded, but often at the expense of the maternal
structures, with resulting deep tears of the vagina
and pelvic floors. "Rotary axis traction" has
been tried innumerable times, and it has seldom
failed when the forceps was applied to the sides of
the pelvis, and never* when it was applied to the
sides of the fetal skull. The resultant lesions were
no deeper or more frequent than in ordinary simple
forceps extractions. The prognosis for the child
was as good as under ordinary conditions. ;

♦Since writing this article, however, I failed in one case
to rotate even though the blades were applied to the
sides of the fetal skull.

BRIEF NOTES ON THE MANAGEMENT OF
OCCIPITOPOSTERIOR POSITIONS OF THE
VERTEX.

LY JOHN O. POL.\K, M.S., M.D.,

BROOKLYN. N. Y.
'professor of obstetrics, N. Y.rpOST-GRADUATE MEDICAL SCHOOL.

The occurrence of a posterior position of the vertex
is always indicative of faulty mechanism, it matters
not whether the fault be a pelvic contraction of the
flattened, general, oblique, or kyphotic form, a large
head, a small child or a defective pelvic floor, imper-
fect flexion of greater or lesser degree, always occurs
at some stage of the mechanism. Consequenth''
when this malposition does present, it suggests some
defection in the factors of labor and a recognition
of the cause in the particular case must be appre-
ciated before any treatment can be instituted.

Diagnosis. — Before labor and during the early
part of the first stage, the diagnosis of occipito-
posterior may be readily made by abdominal palpa-
tion. The dorsal plane is inaccessible, while the
small parts are prominent and found in the middle
section of the abdomen. The head is usually not
engaged at the beginning of labor, which makes the
cephalic prominence marked. The anterior shoulder
is found remote from the median line and the heart
is heard well around toward the flank or not heard
at all. Right occipitoposterior must always be
thought of in right dorsal positions, as it occurs
nearly or quite as frequently as a right anterior posi-
tion. Aleftposterior is less frequent than a right. The

MEDICAL RECORD.

[July 9, 1904

vaginal signs are confirmatory. If the head is
engaged, the small or posterior fontanelle may be
felt opposite one or the other sacroiliac synchron-
drosis with the ball of the occiput posterior. Usu-
ally, however, the head is not engaged at the begin-
ning of labor, and further it is frequently improperly
flexed, because of the conditions which obtain, in the
causation of posterior occiputs. Hence the large
fontanelle is at a lower level and is more easily felt.
Palpation of the ball of the occiput and the relative
location of the ears will make the diagnosis positive.
It must be kept in mind that the most frequent
cause of fetal dj'-stocia is a posterior position of the
vortex and when such is encountered, should there
be any doubt in the mind of the operator as to the
relations of the head to the pelvis an examination
under anaesthesia with the hand in the vagina and
two fingers or half the hand introduced into" the
uterus will remove all uncertainty. The relation
that the sagittal suture bears to the diameters of the
pelvis is a constant index as to the degree of rotation
and must be observed to manage intelligently this
abnormality.

Treatment. — The majority of posterior cases rotate
to the front unaided when the passenger, powers and
passages are normal or can be made to assume rela-
tive normality. Less than 2 per cent, rotate into
the sacrum, notwithstanding that the head must
rotate through 135" to be delivered with the occiput
under the pubes. This rotation takes place either
at the brim, in the cavity of the pelvis or on the
pelvic floor.

When the diagnosis is accurately made in the be-
ginning of labor, posterior positions are not as for-
midable as general!}- believed. The dangers to the
mother are exhaustion, lacerations, and the risks of
instrumental interference. To the child — those of a
prolonged labor. In considering the management of
this abnormality, it is advisable to study the indi-
vidual case as it presents at the time when it is seen
by the accoucher.

Therefore I would classify these conditions as fol-
lows:

1. With the head at or above the brim, flexion
more or less imperfect, and the membranes unrup-
tured. In the presence of these conditions,
postural methods alone deserve our consideration.
The woman should be placed on the side toward
which the occiput points and directed to maintain
this position, which favors anterior rotation and
more perfect flexion of the vertex. The genu-
pectoral position which is mentioned in most of our
textbooks cannot be maintained by the patient
for any length of time and so is only of theoretical
value. Every effort should be made to keep the
membranes intact until complete dilatation of the
cervix is obtained. When dilatation is slow a
colpeurynter will facilitate canalization and preserve
the membranes.

2. After rupture of the membranes with the head
at the superior strait, postural methods may be con-
tinued while efforts are being made to dilate the
cervix with hydrostatic bags, unless the condition
of mother or child demand more radical intervention.

After dilatation, a fair trial having been given to
posture and the natural forces having failed to rotate
the head to the front, manual rotation of the head
to the front and engagement of the head by internal
and external manipulation, under anaesthesia, may
be attempted. This procedure presupposes a dilated
or dilatable cervix. The one hand placed on the
mother's abdomen pushes the anterior shoulder
toward the median line, while the other hand in the
uterus pushes the other shoulder in the opposite
direction, thus rotating the dorsum anteriorlj', as

well as the head, and the tendency to recurrence is
minimized. When the malposition of the occiput
has been corrected, an attempt to engage the properly
flexed and positioned head may be made with the
patient in the Walcher position, either by crowding
the head into the pelvis manually or by tentative
traction with the axis traction forceps. Should this
attempt to engage the head fail, podalic version
may be elected, except when the size of the child
would contraindicate such a procedure. The writer
feels that while version is theoretically the proper
thing to do in these posterior cases, which have
resisted the several eff'orts of the operator to flex
and engage the vertex, experience in estimating
the relative size of the child and the pelvis as well as
the individual dexterity- of the operator will largely
determine whether an axis traction delivery or a
podalic version shall be elected.

When the head presents as an occipitoposterior
in the cavity, anterior rotation maj^ be favored by
posture, used in conjunction with manual aid during
the pain, by pushing the sinciput upward and back-
ward, thus promoting flexion and anterior rotation.
Should the head become arrested and remain sta-
tionary for two hours in the second stage, the forceps
may be applied, either to the sides of the pelvis and
taken off and reapplied as the head assumes its rela-
tion to the different pelvic planes or the axis traction
forceps may be applied to the sides of the head and
be used as rotators as well as tractors, guided by the
relation of the saggital suture.

When a posterior vertex is encountered on the
pelvic floor, the occiput maj^ be rotated to the front
manually or with the reversed forceps, though this
possibility only obtains in the case of a small foetus
on a relatively roomy pelvis. Should attempts at
rotation of the occiput fail and a posterior position
persist, the brow may be pushed upward to exag-
gerate the flexion while the occiput is slipped over the
perineum with more or less tearing of the pelvic floor.

Posterior positions are apt to tire the woman and
exhaust the child. The foetus often becomes asphyx-
iated while in the vagina. The judicious use of
forceps will minimize these risks.

In conclusion I would add, make the diagnosis and
then apply such treatment as the individual case
demands, being governed by the existing conditions
at the time at which the patient is seen by the
attendant.

287 Clinton Avenob.

Exanthematous Eruptions Following Throat Operations.

— From his personal expcrifncc and from a careful study
of the literature of the subject, Louis Fischer believes that
exanthematous eruptions, such as scarlet fever or measles,
have nothing to do \\'ith the operation itself. The in-
fection evidenth' takes place before the operation. The
period of incubation may have been shortened, and that
the disease appear sooner owing to the traumatism. The
question of prophylaxis by means of local pharyngeal
antisepsis to destroy pathogenic bacteria in these regions
is one that deserves attention. It is important to ascer-
tain, if possible, whether or no the patient has been ex-
posed to any infectious disease for a number of days prior
to the operation. The thermometer is of valuable as-
sistance. If the temperature is above normal it is
better to postpone operative procedure until normal
conditions are established. Fischer believes the infection
takes place before the operation, and that the operation
itself lowers the resistance of the body, and shortens the
period of incubation. This \vi\\ account for all of his
cases and those reported by many clinical observers, being
called surgical scarlet fever, when in reality they are true
cases of scarlet fever, infected prior to the operation. —
The Laryngoscope.

July 9- 1904]

MEDICAL RECORD.

Medical Record:

A Weekly Journal of Medicine and Surgery.

GEORGE F. SHRADY, A.M., M.D., Editor.

THO.MAS L STEDMAN, A.M., M.D., Associate Editor.

PUBLISHERS
WM. WOOD & CO., 51, Fifth Avenue.

New York, Jaly 9, 1904.

AUTOINTOXICATION OF INTESTINAL
ORIGIN.
The question of antointoxication is treated quite
extensively by Dr. G. Lyon in the Gazette des Hopi-
iatix for May 14 last. The intestine is a permanent
sotirce of poisons, which under certain conditions
cause grave alterations in the principal organs
(notably the liver, kidneys, and skin) and functional
troubles, among which those of the nervous system
occupy a prominent place. Autointoxication may
exist in connection with diseases involving diarrhoea,
but it is above all associated with those causing
constipation; it is, in short, a consequence of all
intestinal affections.

To understand its genesis, we must at the outset
recognize that digestion is a double process, an
enzymic and a microbic one. Both enzymes and
microbes transform starch into sugar, both emulsify
fats, and both transform albuminoids into peptone.
But the role of the microorganisms does not end
here, for they may act to bring about further and
putrefactive changes, with the formation of sul-
phuretted hydrogen, lactic and butyric acids, and
from the albumins the ptomains and substances of
the aromatic group. Against the poisons so pro-
duced, the normal organism manages to protect
itself principally through the action of the in-
testinal epithelium and the liver which destroy the
majority of the toxic products, while the excretory
organs eliminate the remainder. Given certain
conditions, however, and the toxic products can be
generated in excess of the powers of the organism to
dispose of them, or those powers may fail in point of
efficiency. Of these two conditions, the former is
the more frequent. Various influences may in-
terfere with the normal course of digestion.
Errors in diet, qualitative or quantitative, may
form the starting-point, or the cause may He
in the organism itself. Thus gastric atony,
whether combined (as is frequently the case) with
dilatation or not, plays an important r61e. Or
any one of several modifications of the gastric
juice may initiate the series, by entailing delayed
digestion which means fermentations and putre-
factions. But gastric conditions are as nothing
compared to intestinal, as gastric defects can be
made up by intestinal over-exertion, while for in-
testinal deficiencies there is no compensation. Apart
from organic obstructive conditions, intestinal
atony plays a frequent and very deleterious part,
the more serious the higher in the intestine the
stasis occurs. For once stasis sets in, we are already
in sight of autointoxication. Another expression

of this motor insufficiency is the constipation so
often pre-sent. As other pathological conditions
underlying autointoxication are enteritis (acute
or chronic), colitis with constipation, cancer of the
intestines, etc., but especially chronic appendicitis,
as its rdle is in a number of cases misconceived. The
fetid diarrhoea, which is very frequent in the last
disease, and which is very rebellious to treatment,
ceases at once upon ablation of the appendix.
Autointoxication may then be associated with any
disease of the intestines, those associated with
diarrhoea as well as those connected with con-
stipation, but it is far more frequently associated
with the latter class.

The diagnosis of chronic autointoxication is
easily made ; the yellowish tint of the face with the
coated tongue, fetid breath, anorexia, nausea and
sometimes vomiting, constipation, or diarrhoea
with fetid stools, usually emaciation, sad aspect,
with loss of energy and inaptitude for work, the
whole gamut of nervous troubles (migraine, torpor,
vertigo, insomnia, multiple pains), make up the
picture.

As regards the degree of intoxication taking
place, the severity of the clinical symptoms affords
no accurate indication, and the same is true of the
examination of the stools. Some patients have
numerous very offensive stools with few symptoms,
while others with a few apparently normal stools
show a profound intoxication. It is then impor-
tant to recognize that we have in the condition
of the urine (in which the majority of the toxic
products is excreted), a quite accurate index to the
state of affairs. Besides the bodies produced by
both enzyme and microbic action, the micro-
organisms of the intestinal tract are capable of
giving rise to putrefactive products; bodies belong-
ing to thefatty|series (ammonium butyrate,caproate,
valerianate; ptomains), and to the aromatic series
(phenol, paracresol, indol, scatol, aromatic
oxyacids). These appear in the urine as sulpho-
compounds, their toxicity having been attenuated
by combination in the liver with sulphuric and
glycuronic acids. The aromatics have not the
toxicity of the ptomains but they are excreted
parallel with them, and constitute, therefore, a
rather exact index to the amount of the ptomains.
A number of observations have now shown that
putrefaction of the food in the prima vias is the only
source of the "ethereal sulphates" in the urine, and
that they are never derived from any of the albumi-
noids of the organism itself. Thus, in animals with
sterilized intestines, fed with sterile food, the urine
shows no trace of phenol, indol, or scatol. More
important, from the practical standpoint, is the fact
determined by White, Poehl, Herschler, Winter-
nitz, and Bernacki, that limitation to a hydro-
carbonaceous diet, brings about a reduction of
these substances in the urine to one-third of the
previous amount. On the other hand constipation
increases the amount of the ethereal sulphates in
the urine, as does also all obstructive conditions
of the intestines. The latter fact would naturally
lead one to suppose that purgatives would bring
about a decrease. But the action of these drugs
is, in fact, not a uniform one, castor oil and the
salines increasing the amount of the urinary ethereal
sulphates, while calomel decreases them markedly..

MEDICAL RECORD.

[July 9, 1904

As regards successful treatment, the first indica-
tion is the retardation of the existing intestinal
putrefaction. For this purpose sterilization of
the intestine by means of drugs has been tried,
but the practice is to-day discredited as an im-
practicable Utopia. The effects of naphthol and
its derivatives are, it must be said, much disputed
and most disputable. Besides naphthol exercises
an irritation of the most active description on the
stomach, and its prolon;j;c(l use can cause glandular
atrophy. Also the administration of hydrochloric
acid is useless, at an}'^ rate as regards intestinal
antisepsis, and it may be remarked that hyper-
chlorhydria does not include antisepsis in its sympto-
matology. The same is. however, not true of
lactic acid, which diminishes markedly the urinary
ethereal sulphates.

It is, however, by diet that the effect is to be
produced. To start with, the albuminoids are to be
reduced to a minimum, for it is their fermentation
which yields the toxins. Combe recommends
"saturation" of the patient with hydrocarbona-
ceous articles of diet, the word "saturation" being
taken in its most literal acceptation. This anti-
putrefactive diet of Combe yields the most ex-
cellent results. Also Poehl and Bemacki have
proven that a milk diet diminishes the ethereal
sulphates, and that on such a diet the stools contain
no indol, scatol. or phenol, but only leucin and
tyrosin. This resistance of milk to putrefaction
is attributed by Winternitz to the contained lactose,
which on fermentation produces lactic acid which
in its turn inhibits putrefaction. Similarly, fresh
cheese has been shown to possess antiputre-
factive properties. As regards eating, meals should
be alternately solid and liquid, the patient not eating
when he is drinking, or vice versa. Rovighi and
Schumann have shown that this course involves a
diminution of the ethereal sulphates. After each solid
meal the patient should lie down, without sleeping.
Green vegetables and all fruits, cooked or raw, are
to be excluded. After a variable time the milk-
farinaceous diet is to be mitigated on trial with
meat, the yolk of eggs, and green vegetables.

Enteroclysis has more value than as an enema.
The water is absorbed, relieving thirst and assisting
in the lavage of the blood. The tube should be in-
troduced with the patient lying on the right side
with the left leg flexed upon the abdomen, and very
slowly with successive pauses, to allow of an un-
folding of the rugae in advance of it. The solution
is best an isotonic one (7 parts of sodium chloride
per 1,000) introduced at 38°, and under a low pressure
(with an elevation of only 15 to 20 centimeters),
to avoid spasm of the intestine. Purgatives and
lavage should be alternated. The purgative of
election would seem to be calomel.

In certain cases with profound intoxication (as
evidenced by nervous troubles, oliguria, subicterus,
etc.) in which an immediate effect is urgently
demanded, subcutaneous injections of saline
solutions are to be resorted to, as this is the onlv
method which can be relied upon for a rapid de-
intoxication of the organism.

The immediate symptoms being relieved, in the
further treatment recourse should be had to hydro-
therapy, open-air life, exercise, subcutaneous
injections of sodium cacodylate and of strvchnine;

and gastrointestinal massage is one of the best
means at our disposal for the correction of the
stasis.

PARATYPHOID FEVER.

In the Scottish Medical and Surgical Journal for
May is a paper by Dr. R. D. Keith on paratyphoid
fever. The first part of the article is devoted to a
consideration of the disease chronologically, and
states that the first case was described by Achard
and Bensaude of Paris in 1896, who isolated a
paratyphoid bacillus. Schottmuller of Hamburg
was the first observer to take up the subject in
Germany, who isolated the specific organism of the
disease and gave to the fever the name paratyphoid
on account of its close resemblance to typhoid fever.
Schottmuller concluded, from the investigation of a
large number of cases of clinical typhoid in the
General Hospital of St. George in Hamburg, that
the bacilli isolated were the cause of the disease, and
that of six cases there were two groups, one of which
contained two, and the other four bacilli. These
two groups, subsequently described in the literature
as type "A" and type "B," differ in degree both
culturally and in their serum reactions. It was
found that the serum reactions of the members of
the first group corresponded with one another, but
not with those of the second group, and that while
the serum reactions of the members of the second
group corresponded with one another they differed
from those of the first. These conclusions in all
important details have been confirmed by the
investigations of many observers, including several
Americans.

As to the clinical characteristics of paratyphoid
fever, observations of more than one hundred cases
have been published, of which, however, only 46
are available for the purpose of a minute clinical
analysis. Dr. Keith describes the disease — although,
as he confesses, somewhat loosely — as an acute in-
fectious process caused by a bacillus closely re-
sembling in many particulars the typhoid bacillus,
and the symptoms and course of the disease closelv
resembling those of typhoid fever. The onset is
marked by headache, lassitude, loss of energy, and
general weakness. Occasionally there is epistaxis,
and in some cases vomiting and pain in the abdomen.
By the time the patient comes under observation he
is feverish and may feel chilly, but regularly marked
rigors are hardly ever met with. As a rule, the
temperature does not rise above a moderate height
(102° F. or thereby), except in the more severe cases,
nor does it remain for more than a few days at this
height continuously.

Occasionally a critical fall is observed, and it has
been observed by most investigators that even at its
height the temperature has, as a rule, a remittent or
intermittent character. The pulse is, as a rule, quite
regular but somewhat small. Its frequency, accord-
ing to some, is not increased at the commencement of
fever.

A roseolar eruption resembling that of typhoid
fever was present in thirty-two out of forty-six
cases. It was described in some cases as occurring
not only on the skin of the abdomen and chest but
also on the back and limbs, and in one case even on
the face. The tongue is generally covered with a
moist white coating, but is occasionally dried and
furred.

July 9, 1904]

MEDICAL RECORD.

Diarrhoea is more prominent than constipation,
and is sometimes present at the commencement of
the disease. The abdomen is not, as a rule, markedly
distended, nor is tenderness a prominent feature,
but pain is in some cases present, and iliac gargling
is an almost invariable accompaniment of the
disease. The spleen is enlarged in the majority of
cases, but so far as can be ascertained during life
the liver is not affected. The urine during the
course of the disease shows a deposit of lithates.
Albuminuria, when present, is, as a rule, not marked
and is found during the height of the fever. Hyaline
and granular casts have been observed, and in one
case blood was found to be present. In nineteen
out of forty-six cases the urine was found to give
the diazo reaction, and in eight the test for indican
was positive. The heart is practically always un-
affected. With regard to the lungs, bronchitis is
comparatively common, and emaciation is not so
marked in this disease as in typhoid fever.

Of the complications observed, bronchitis is the
most common. Pharyngitis is not uncommon, and
next in frequency to it comes bronchopneumonia.
Thrombosis of the femoral veins, pleurisy, phlebitis
of the veins of the leg, endocarditis and cystitis
have also been observed. Sequelae have not de-
finitely been known to occur.

Up to the present only three authentic fatal cases
have been described. In all of these paratyphoid
bacilli have been isolated from the organs after
death, but in no case was any characteristic lesion
found. The appearances were in most cases those
of an acute general infection.

Studies undertaken to show the morphology,
cultural characteristics, and behavior toward
various media of the bacillus of paratyphoid fever
bring out the characteristics distinctive of the
paratyphoid bacilli "A" and "B." It is shown:
(i) That there is a distinction between "A" and
"B" paratyphoid bacilli. (2) That as regards the
characteristics here alluded to paratyphoid "A"
organisms are on the whole nearer bacillus coli than
the "B" group. (3) That bacillus paratyphoid
"B" is identical as regards its cultural character-
istics with Gartner's bacillus. (4) That "A" and
"B" paratyphoid bacilli are distinct both from the
bacillus coli communis and the bacillus typhosus.

Dr. Keith considers the serum reactions in cases of
paratyphoid infections and their bearing on the serum
test in typhoid fever. The chapter in which this
portion of the subject is dealt with is both too
long and too technical to be adequately treated in
an editorial. The value of immune sera is pointed
out (i) As a means of identifying bacilli quickly.
(2) As a means of showing the more exact rela-
tionship of bacilli to other members of a family or
group.

The author gives the following resum6 of the
conclusions drawn from the investigations considered
by him: (i) That there exists a disease which
simulates the disease known as typhoid fever so
closely that they can only be distinguished by
bacteriological means. (2) That the disease is
caused by an organism which exists in two varieties
and which may be regarded as bacteriologically
intermediate between the bacillus typhosus and the
bacillus coli communis. (3) That the disease is on
the whole mild and that the prognosis is good. (4)

That the treatment of the disease is similar to that
of typhoid fever. (5) That the disease spreads
in the same manner as typhoid fever, a nd that the
same hygenic and general measures should be taken
in cases of this disease as are adopted in typhoid
fever. (6) That in suspected typhoid-like cases
a bacteriological examination is of the greatest
importance both for diagnosis and prognosis and
should be made wherever it is possible. (7) That
up to the present the disease must be regarded as
acute general infection in which no definite local
lesion has been shown to exist.

Paratyphoid fever is probably conveyed in the
same manner as is typhoid fever. It is not markedly
infectious. The incubation period is about fourteen
days, the spots appearing from the twentieth to
twenty-sixth day. Perhaps the most valuable de-
ductions to be drawn from the investigations of para-
typhoid fever is that experiments have tended to
show that immune sera can be produced which have
a protective power against lethal doses, not only of
homologous organisms but also of organisms which
are related, thereby indicating to some extent the
possibility of a new line of treatment in cases of
infectious diseases.

Wright, as is well known, is of the opinion that
typhoid fever can be warded off completely in some
cases and in others rendered less severe by injections
of dead cultures. Dr. Keith suggests that the
indications given by the results of the experiments
on animals with protective sera in the case of
bacillus t3'phosus and allied organisms is but the
initial stage of a new curative method of treatment.
This matter, however, requires further elucidation
before any large definite statements can be made
regarding it. ' Nevertheless, it may be said that
the prospect is hopeful.

Tr.ichoma as an Epidemic and Maritime Disease.

In the annual report of the Surgeon-General of
the Public Health and Marine Hospital Service for
the fiscal year 1903, recently issued, Passed Assistant
Surgeon J. M. Eager has an article on the above
subject. The writer points out that the trans-
missibility and relation to shipping of trachoma
are brought prominently before the observer in
connection with the inspection of emigrant ships
in Italy. In view of the contagiousness of tra-
choma, the Italian Government now refxises to
allow the embarkment of cases of active ophthal-
mia on emigrant ships leaving Italy, either for
South America, where there is no prohibition
against the entrance of trachoma, or for the United
States. The object of this ruling is to prevent the
spread of the disease aboard ship.

Dr. Eager reviews the history of trachoma from
an epidemiological standpoint, and says that
while it may be considered as a disease which,
though known in ancient times to be contagious,
was not noted to take on an epidemic character
until recent centuries. Hippocrates, Galen, Plu-
tarch of Cheronca, and Rhases, the famous Arabian
physician of the ninth century, mention oph-
thalmia as an eminently contagious malady. The
Rabbi Moses, a great exponent of the doctrines of
Galen, says in his aphorisms that to gaze steadily
into the eyes of a trachomatous person is enough
to make anyone's eyes water, and that continuous
contact with sufferers from ophthalmia generally
results in contracting the disease.

The name trachoma was given to the affection

MEDICAL RECORD.

[July 9, 1904

through the writings of Prospero Alpino, an Italian,
who visited Africa in the sixteenth century for the
purpose of studying Egyptian medicine. It was
through the campaigns of Napoleon that trachoma
became prevalent throughout Europe. All the
armies engaged in those wars being more or less
aflected by the disease. In 1820 Guille of Paris
demonstrated the contagiousness of trachoma.

The only record found in literature of trachoma
as a maritime disease is that given by Guill6
(Biblioth(:que ophthalmologique, Paris, 1820). The
disease occurred on a slaveship, Le Rodeur, which
on the voyage out was free from ophthalmia, but
whose slaves when sixteen days from Guadeloupe
exhibited signs of the malady, which soon spread
in the most rapid manner.

At the present time trachoma is notably endemic
in Arabia, Egypt, Italy, Spain, Western Russia,
Poland, Ireland, and South America. Exact sta-
tistics as to the prevalence of trachoma in Italy are
not available, but these are, in most instances, in-
complete, and in others, owing to inherent disad-
vantages, entirely indecisive. However, enough is
known to show that the disease is very prevalent in
many ports of Italy. Dispensary reports establish the
fact that trachoma is greatly on the increase in that
country, while Professor Fortunate states that in some
of the maritime places of Sicily and Sardinia, from all
available means of observation, it may almost be
said that the entire population is trachomatous.

Dr. Eager ends an instructive paper by saying
that the statistics of the medical inspection made
in Italy for the United States are of little value in
estimating the prevalence of trachoma in Italy for
the reason that the figures are distorted by the fact
that often persons notably trachomatous do not
attempt to take passage or are refused the same
by the transportation companies prior to the day
of sailing, and so do not appear at the regular med-
ical visit. . . . Then, too, many persons, some
not trachomatous, but fearing they may fall under
suspicion, and others really victims of the disease,
practise a sort of universe malingery at the time
of the inspection. Adrenalin with cocaine hydro-
chlorate is a favorite prescription for eyedrops.
By its application, a blanching of the conjunctiva
is brought about, a condition which, even in the
absence of other evidence, is sufficient to put the
person under observation until the disappearance
of drug effects has rendered proper examination
practicable.

Food Preservatives.
A committee has recently been sitting, taking
evidence as to adulterations and the use of pre-
servatives in food. It has been especially consider-
ing the question of the use of preservatives in
food. According to the New York Times. Dr.
Frear, in discussing this contention, said that the
testimony of the manufacturers had pretty generally
been that such goods could not be packed with-
out preservatives without a certain percentage of
loss, but we must remember that the housewife
who puts up her own catsup and preserves also
suffers a percentage of loss. "The best opinion,"
Dr. Frear says, "seems to be against the use of
preservatives as a general proposition as injurious,
but, on the other hand, it is argued that the quantity
used is so small as to be harmless in the product's
in which they are most necessary. The manufac-
turers seem to believe that it ought to be enough
if all goods containing preservatives were plainly
labeled, so that the consumer could see for himself,
and take the responsibility for what he is taking
into his stomach."

It is expected that the Secretary of Agriculture
will be able in a few months to draw up a set of
standards which will define what is meant by purity
in foods, and what constitute adulterations. The
Medical Record has always taken the view that
preservatives [should, as far as is possible be absent
from foodstuffs. In fact, there is little doubt that
in the large majority of cases articles of food re-
quire no preservatives. By allowing the use of
foreign matter in food, the thin edge of the wedge
for all kinds of deception is allowed to enter. Un-
doubtedly, if the use of preservatives is permitted
at all, food so treated should be plainly labeled.
The question of pure food is a momentotis matter,
and one which directly affects the whole commun-
ity. Ignorant persons must be protected against
themselves, and the manufacturers must remember
that it is not only their interests which are at
stake but the welfare, to a greater or lesser extent,
of the entire population of the country. Selfish
interests cannot be allowed to prevail over the
good of the many, and legislation should be strictly
enforced which clearly defines the relative position
of manufacturers and the general public with regard
to food preservatives.

The Medic.\l Library Movement in the United
States.

Standard books on medicine and surgery, and
the latest works on these subjects, together with
the most recent medical literature, are considered
to be essential to the phj^sician of the present
day. Without access to these the up-to-date
Hiedical man feels to some extent lost, for he
recognizes that it is necessary for him to keep
abreast with the times and to know something
of everything that is going on in the medical world
everywhere. Thus the medical library has become
an absolute need, and the main provider of medical
and scientific pabulum to the practitioner. As a
factor in medical education the library is of in-
estimable value, in this respect equalling if not
transcending any other means.

Dr. Albert T. Huntington of Brooklyn, in the
Medical Library and Historical Jonrital. for April,
1904, writes on the medical library movement in
the United States. The first one in this country
was founded in 1760, but it is only within the past
forty years that the great medical libraries of
to-day have been built up, and only within the
last decade that the medical library movement has
become active and widespread.

Dr. Huntington gives a list of the various medical
libraries in the countrj', the date of their foundations,
and the number of volumes contained in each.
There are in the United States 215 of such insti-
tutions, while the number of volumes in these is
estimated at 1,023,295.

The author points out that if we should assume
that all the libraries in the list compiled by him are
in an active state of existence and their resources
readily available to the profession, two striking
facts are very evident: First, that certain centers
are oversupplied with medical libraries, and that
the fusing of several distinct collections into one
great library whose resources should be free to the
whole profession could not be other than ad-
vantageous to the best interests of all concerned.
Second, that there are certain large sections of
the countr}- which are utterly barren of adequate
medical library resources.

Dr. Huntington is of the opinion that there are
two requisites for the establishment and perma-
nent success of a medical library: First, a desire
on the part of the local profession to have a library;

July 9, 1904]

MEDICAL RECORD.

second, the control of that library, wherever the
books are housed, by the medical profession.
Therefore, it is best, whenever practicable, that
the library should be separate, and under the
auspices of some general medical organization.
The foregoing is undoubtedly good advice and
should be followed as far as is possible.

The medical library movement has evidently
taken firm root in the United States, and from
all apprearances will flourish in the future to a
greater extent than at present.

Nrlitii nf tV Wrrk.

Change in the Examination for the Army Medical
Service. — The examination of applicants for com-
mission in the Medical Corps of the Army was mate-
rially modified on July i. Immediate appointment
of applicants after successful physical and profes-
sional examination — the latter embracing all sub-
jects of a medical education — will be discontinued,
and hereafter applicants will be svjbjected to a pre-
liminary examination and a final or qualifying
examination, with a course of instruction at the
Army Medical School in Washington intervening.
The preliminary examination will consist of a rigid
inquirj- into the physical qualifications of applicarts
and written exammat'on in mathematics (arithme-
tic, algebra, and plane geometry); geography; his-
tory' (especially of the United States) ; Latin gram-
mar, and reading of easy Latin prose ; English gram-
mar, orthographv, composition; anatomj'; physiol-
ogy; chemistry and physics; materia medica and
therapeutics; normal histology. The subjects in
general education above mentioned are an essertial
part of the examination and cannot under any cir-
cumstances be waived. The preliminary examina-
tion will be conducted concurrently throughout the
United States by boards of medical officers at most
convenient points; the questions submitted to all
applicants will be identical, thus assuring a thor-
oughh- competitive feature, and all papers will be
criticised and graded by an Army Medical Board in
Washington. Applicants who attain a general aver-
age of 80 per cent, and upward in this examination
will be employed as contract surgeons and ordered
to the Army Medical School for instruction as can-
didates for admission to the Medical Corps of the
Army ; if, however, a greater number of applicants
attain the required average than can be accommo-
dated at the school the requisite number will be
selected according to relative standing in the exami-
nation.

The course of instruction at the Army Medical
School will consist of lectures and practical work in
subjects peculiarly appropriate to the duties which
a med'cal officer is called upon to perform. While
at this school the students will be held under mili-
tary discipline, and character, habits, and general
deportment will be closely observed. The final or
qualifjnng examination will be held at the close of
the school term, and wilt comprise the subjects taught
in the school, together with the following professioral
subjects not included in the preliminary examina-
tion: Surgery, practice of medicine; diseases of
women and children; obstetrics; hygiene; bacteriol-
ogy, and pathology ; general aptitude will be marked
from observation during the school term. A general
average of 80 per cent, in this examination will be
required as qiialifying for appointment, and candi-
dates attaining the highest percentages will be
selected for commission to the extent of the ex'sting
vacancies in the Medical Department. Candidates
who attain the requisite general average who fail to
receive commissions will be given certificates of grad-

uation at the school and will be preferred for appoint-
ment as medical officers of volunteers or for employ-
ment as contract surgeons; they will also be given
opportunity to take the qualifying examination \\ ith
the next succeeding class.

It is not thought that, for the present at least, the
number successfully passing the preliminary exami-
nation will be greater than can be accommodated
at the Army Medical School, nor that the number
qualifying for appointment will exceed the number
of vacancies. If, however, the class of candidates
qualifying should be larger than is now thought, the
young physicians who fail to receive commissions
will not have wasted their time, as the course of
instrviction at the school, while in a large measure
specialized to Army needs, is such as will better fit
them for other professional pursuits, and further-
more they will have received a fair compensation
while under instruction.

Admission to the preliminary examination can be
had only upon invitation from the Surgeon- General
of the Army, issued after formal application to the
Secretary of War for permission to appear for exami-
nation. No applicant whose age exceeds thirty
years will be permitted to take the examination ;
this limit of age will be rigidly adhered to. Hospital
training and practical experience are essential req-
uisites, and an applicant will be expected to present
evidence of one year's hospital experience or its
equivalent (two years) in practice. The first pre-
liminary examination under the amended regula-
tions above referred to will be held about August i .
1904; those desiring to enter the same should at
once communicate with the Surgeon-General of the
Army, Washington D. C, who will furnish all pos-
sible information in regard thereto.

New York State Hospital for Incipient Tuber-
culosis. — This institution was opened on July i,
at Ray Brook, Essex County, under the superin-
tendence of Dr. John H. Pryor. The following
information concerning the admission and main-
tenance of patients is from the act establishing
a State Hospital in the Adirondacks for the treat-
ment of incipient pulmonary- tuberculosis.

Free Patients. — The trustees of the hospital are
hereby given power and authority to receive therein
patients who have no ability to pay, but no person
shall be admitted to the hospital who has not been
a citizen of this State for at least one year preceding
the date of application. Every person desiring
free treatment in the hospital shall apply to the
local authorities of his or her town, city, or county
having charge of the relief of the poor, who shall
thereupon issue a written request to the superin-
tendent of said hospital for the admission and
treatment of such person. This request must
state in writing whether the person is able to pay
for care and treatment while at the hospital. The
requests will be filed by the superintendent in a
book kept for that purpose in the order of their
receipt by him. When the hospital is completed
and ready for the treatment of patients, or when-
ever thereafter there are vacancies caused b}^ death
or removal, the superintendent shall issue a re-
quest to an examining physician, in the same city
or county, or, if there is no such examining phy-
sician in the city or county, then the nearest exam-
ining physician, for the examination by him of
said patient. Upon the request of the superin-
tendent the examining physician shall examine
all persons applying for free admission and treat-
ment in the institution, and determine whether
such are suffering from incipient pulmonary tuber-
culosis. No person shall be admitted as a patient
in the institution without the certificate of one of

MEDICAL RECORD.

[July 9, 1904

the examining phj'sicians certifying that such ap-
plicant is suffering from incipient pulmonary-
tuberculosis. Admission to the hospital shall be
made in the order in which the name of applicants
shall appear upon the application book kept by
the superintendent of the hospital, in so far as such
applicants are subsequently certified by the
examining physician to be suffering from incipient
pulmonary tuberculosis. Everj- person who is
unable to pay for care or treatment shall be trans-
ported to and from the hospital at the expense of
the local authorities. At least once in each month
the superintendent of the hospital shall furnish
to the comptroller a list countersigned by the treas-
urer of the hospital of all the free patients in the
hospital, together vith sufficient facts to enable
the comptroller to collect from the proper local
official having charge of the relief of the poor such
sums as may be owing to the State for the exami-
nation, care and treatment of the patients who
have been received by the hospital and who are
shown to be unable to pay for their care and treat-
ment. The comptroller shall thereupon collect
from the local official the sums due for the care and
treatment of each such patient at a rate not ex-
ceeding five dollars per week for each patient.

Private Patients. — Applicants for admission to
this institution who are able to pay for their care
and treatment are not required to obtain a written
request from the local avithorities having charge
of the relief of the poor, but should apply in person
to the superintendent, who will enter the name of
the applicant in the book to be kept by him for
that purpose, and when there is room in the hos-
pital for the admission of the applicant without
interfering with the preference in the selection of
patients, which shall always be given to the in-
digent, such patients shall be admitted to the hos-
pital upon the certificate of one of the e.xamining
physicians, which certificate shall be kept on file
by the superintendent. The trustees shall have
power and authority to fix the charges to be paid
by patients who are able to pay for their care and
treatment in the hospital or who have relatives,
bound by law to support them, who are able to pay
therefor.

Examining Physicians. — In the Manual of the
State Board of Charities for 1903, it is stated that
the trustees of the New York State Hospital for
the Treatment of Incipient Pulmonary Tubercu-
losis will appoint in all the cities of the State rep-
utable physicians, citizens of the State of New
York, to examine all persons applying for admission
to the hospital. There are to be not less than two
nor more than four of such examining physicians
appointed in cities of the first-class, and two each
in cities of the second and third class. The exam-
ining physicians must have been in the regular
practice of their profession for at least five years,
and must be skilled in the diagnosis and treatment
of pulmonary diseases. Their fee for each patient
examined will be three dollars. The law expressly
provides that not more than one-half of all the
physicians to be appointed under this section shall
belong to the same school of medical practice.
The examining physicians for New York City are
Dr. H. M. Biggs and Dr. Egbert Le Fevre. Other
examiners throughout the State are Dr. S. B. Ward
of Albany, Dr. Eisner of Syracuse, and Dr. H. R.
Hopkins of Buffalo.

Examinations of the Public Health and Marine
Hospital Service.— A board of officers will be
convened to meet in Washington, D. C, Monday,
October 3, 1904, for the purpose of examining

candidates for admission to the grade of a.ssistant
surgeon in the Public^Health and Marine Hospital
Service. Candidates must be between twenty -two
and thirty years of age, graduates of a reputable
medical college, and must furnish testimonials from
responsible persons as to their professional and
moral character. The usual order of the examina-
tion is (1) physical, (2) oral, (3) written, and (4)
clinical. In addition to the physical examination,
candidates are required to certify that they believe
themselves free from any ailment which would
disqualify them for service in any climate. The
e.xaminations are chiefly in writing, and begin with
a short autobiography of the candidate. The
remainder of the written exercise consists in exam-
ination on the various branches of medicine, sur-
gery, and hj-giene. The oral examination includes
subjects of preliminarj- education, history, literature,
and natural sciences. The clinical examination is
conducted at a hospital and, when practicable,
candidates are required to perform surgical opera-
tions on a cadaver. Successful candidates will be
numbered according to their attainments on exam-
ination, and will be commissioned in the same order
as vacancies occur. Upon appointment the young
officers are, as a rule, first assigned to duty at one
of the large hospitals, as at Boston, New York, New
Orleans, Chicago, or San Francisco. After five
years' service, assistant surgeons are entitled to
examination for promotion to the grade of passed
assistant surgeon. Promotion to the grade of
surgeon is made according to seniority, and after
due examination as vacancies occur in that grade.
Assistant surgeons receive sixteen hundred dollars;
passed assistant surgeons, two thousand dollars,
and surgeons, twenty-five hundred dollars a year.
When quarters are not provided, commutation at
the rate of thirty, forty, and fifty dollars a month,
according to grade, is allowed. All grades above
that of assistant surgeon receive longevity pay,
ten per centum in addition to the regular salary
for every five years' service up to forty per centum
after twenty years' service. The tenure of office
is permanent. Officers traveling under orders are
allowed actual expenses. Further information may
be obtained by addressing the Surgeon-General,
Public Health and Marine Hospital Service, Wash-
ington, D. C.

The Sanitary Degradation of Santiago. — On Jul}- i
the municipal government of Santiago de Cuba dis-
charged forty sweepers of the street cleaning force
and fifteen cartmen, alleging that the step was made
necessary by lack of funds. The remainder of the
force refused to work until they had been paid their
wages for May and June. It is stated that the streets
have beer in a filthy condition since the flood, and
many families are moving to the country to escape the
epidemic, which they fear may result from the neglect
of all sanitary precautions. The local press bitterly
criticises the Havana government for its failure to
provide and carr\- out necessary sanitary measures,
and is urging the foreign consuls to bring the situa-
tion to the notice of their governments.

Popular Tracts on the Prevention of Tuberculosis.
— The Committee on Sanitation of the Central
Federated Union and the Committee on the Preven-
tion of Tuberculosis of the Charity Organization
Society have published a pamphlet on the prevention
and cure of pulmonary tuberculosis, which bears
the title, "Don't Give Consumption to Others;
Don't Let Others Give It to You." It describes a
number of the sanitary safeguards, which tend to
check the spread and progress of the disease.
Copies of the pamphlet may be had in English,

July 9. 1904]

MEDICAL RECORD.

Yiddish, Bohemian, and German upon application
to the Charity Organization Society, 105 East
Twenty-second Street.

Excess of Zeal on the Part of a State Medical
Examiner. — The State Board of Medical Exam-
iners of California secured, on June 18, the con-
viction of another physician for«practising without
a license, and the minimum fine of $100 was as-
sessed. Following immediately upon this case,
another action was brought for which the president
of the board is being severely censured. A young
physician, a graduate of the University of Basel,
and recently a fellow at Johns Hopkins, arrived
in the city shortly after the last regular session of
the board. Recognizing that he could not engage
lawfully in practice, he refrained from opening an
office. In recognition of his capability, however,
he was asked to serve as the assistant to one of the
attending physicians of the city and county hos-
pital. Even in this capacity, it is stated, he re-
frained from writing prescriptions. His conduct,
nevertheless, met with the disapproval of the presi-
dent of the board, who regarded it as a violation
of the law, and summoned him to his office. Fail-
ing to arrive at a satisfactory understanding, he
placed him in the custody of a police officer in wait-
ing, and a trial followed on June 21 and 22. The
police judge has withheld his decision, but stated
that no fine will be imposed, in case of conviction,
owing to the peculiar circumstances. From the fact
that the cities of the Pacific coast are overrun by
the worst of charlatans, who make of the tourists
an easy pre}-, the action of the official who caused
the arrest of a young man of ability who was only
waiting for the opportunity to obtain legal recog-
nition, has caused much comment.

An Illegal Practitioner Fined. — A man, styling him-
self a doctor 01 therapeutics, on the diploma of the
Eastern College of Electrotherapeutics and Psycho-
logic Medicine of Philadelphia, was recently convict-
ed in Philadelphia of practising medicine illegally,
and made to pay a fine of S200. This was the result
of a suit instituted by the Pennsylvania State Board
of Medical E.-vaminers.

Health Department Changes. — Dr. Thomas Dar-
lington, president of the Health Department,
transferred all the assistant sanitary superintendents
last week. He said it was "for the good of the
service." Dr. Walter Bensall was sent from Man-
hattan to Brooklyn, Dr. P. J. Murray from Brooklyn
to Queens, Dr. Gerald Sheil from the Bronx to
Manhattan. Dr. J. T. Sprague from Richmond to
The Bronx, and Dr. J. P. Moore from Queens to
Richmond.

Dr. Emily Dunning, who was the first woman to
be appointed an ambulance surgeon, has become, in
the regular course of service, house surgeon of
Gouverneur Hospital and began her duties on
July I.

Ambulance Accidents. — The third collision of a
Bellevue Hospital ambulance with a Third Avenue
electric' car occurred a few days ago. The surgeon
in each instance was seriously injured, and two of
them are now in the' hospital suffering from the
results of their injuries. It would seem to be
advisable for the drivers of ambulances to slow up
when approaching car crossings, until they see that
the coast is clear, even at the expense of losing a
few seconds in responding to the call.

The New Vienna General Hospital. — On June
21, 1904, the Emperor of Austria laid the corner-
stone of the new AUgemeines Krankenhaus. to
take the place of the present famous building.

The new hospital will in reality be a village of
fifty buildings and will contain every device and
appointment known to medical science. It is
the aim of the directors of this gigantic hospital to
make it the finest, best, and most completely
equipped hospital in the world. It will be built
upon one of the hills of Vienna, overlooking the
present site, and the grounds will be much more
beautiful than those of the present hospital.

Dr. Charles F. Roberts, Sanitary Superintendent
of the Health Department of this city, on July i
received a medal from his associates commemorating
thirty-six years of service in the department. Dr.
Darlington presented the medal in the rooms of the
Health Department. In thanking his friends. Dr.
Roberts recalled the fact that thirty-six years ago
the population of New York was 800,000 and the
death rate 36 a thousand, while to-day, with a
population of 3.800,000, the death rate is 19 a
thousand.

The Late Dr. Grant H. Richmeyer. — At a regular
meeting of the Medico-Surgical Society, held Friday,
May 20, 1904, the following resolutions were
adopted :

Whereas, The society has learned with deep
regret of the death of Dr. Grant H. Richmeyer on
the 2ist of April last.

Resolved, That the profession as well as the
society has lost a valued member, whose genial
character as a man and ability as a physician was
esteemed by all his associates,

Rcsohcd, That a copy of these resolutions be
transmitted to his family as an evidence of our
respect and of our sincere sj'mpathy in their afflic-
tion; and that they be published in two of the
Medical journals of this city. Robert J. Devlin,
J. D. Nagel, Henry Griswold, Committee.

Obituary Notes. — Dr. Bry.\n Gilmore Wilh.\ms,
late assistant physician to the Long Island State
Hospital at Kings Park, died at sea on May 13.
He was a graduate of Bellevue Hospital Medical
College in the class of 1893. Dr. Williams was held
in the highest esteem by his colleagues, both as a
co-laborer and as a sincere friend. His sympathetic
attention and genial good nature added much
toward the betterment and for the happiness of the
patients under his charge. At a stated meeting of
the medical staff of the Long Island State Hospital,
June 23, 1904, the folio wing resolutions were adopted:

Resolved, That we learn with feelings of deepest
sorrow of the death of our late associate, Dr. Bryan
G. Williams, which occurred at sea May 13, 1904.

Resolved, That we desire to express to the family
our sincere sympathy in this hour of sad bereave-
ment.

Resolved, That a copy of these resolutions be
sent to his relatives and for publication in the medi-
cal journals, and filed with the records of this hos-
pital.

Dr. M.\RY E. P.\RTRiDGE of Bennington, Vt.,
was drowned in Lake Champlain, near Bennington,
on June 29. She was a graduate of the New York
Medical College and Hospital for Women in the
class of 1884.

Dr. Thom.\s Flint, a native of New Vineyard,
Me., died on his ranch, near San Juan, Cal.,
Tune 19. in the eighty-first year of his age. He
was a graduate of the Jefferson Medical College in
the class of 1849. He had lived in California since
1 85 1, was a member of the State Medical Society
and of the American Medical Association, and had
taken an active part in all public affairs, serving
at one time in the capacity of State senator.

MEDICAL RECORD.

[July 9, 1904

(Harxtspaxiiinut.

OUR LONDON LETTER.

(From Our Special Correspondent.)

HOSPIT.\L SUXD.W PYOPNEU.MOTHORA.X ELASTICITY OF

AORTA A NURSING HOME COMPANY ANESTHETIZED

CATS SIR OLIVER LODGE ON EDUCATED MEN WHAT IS

BRANDY ? OBITUARY.

London. June 17. 1004.

Hospital Sunday has come and gone. The most striking
event in it was the discourse of the Bishop of Stepney at
St. Paul's Cathedral. He made it the opportvmity of
reproving the rich and pleasure-loving people of the mt-trop-
0I&. Into the season — which he described as the festival
of wealth and pleasure — he described hospital Sunday as
coming as a shadow of suffering "and in the name of the
poor of awful London" crying aloud, "Give an account
of thy stewardship." He declared the love of money was
spreading without the least increase in the sense of stew-
ardship, and quoted a distinguished diplomat, who, after
many years abroad, said, "When I left London and went
out of London society it was indeed exclusive and some-
what selfish, but it was under some sort of control; I return
to find it a rabble, devoted to the worship of money and
what money can buy." The craving for pleasure has
become a disease, said the bishop — a disease manifesting
itself in a want of consideration for others that would
never be possible in a healthy mind. He instanced ladies
at the stalls of charitable bazaars with beautiful dresses
not paid for, the unpaid bill meaning to the poor dress-
maker, harrassed for want of capital, the loss of home and
the support of aged parents or invalid sisters. To this
indictment the bishop added, "I speak of what I know,"
and went on to declare that the disease was as ripe in the
middle classes. There were some, he said, who talked of
throwing the hospitals on the rates. "If that came to
pass," he concluded, "the last tie which binds the wealth
of London to the spirit of stewardship would be snapped "
Something might certainly be said in reply to the bishop's
heavy indictment, but it would not hurt the fashionable
congregation, and the wealth of the city has always been
ready to assist.

On this occasion the collection at St. Paul's amounted
to ^5,000, and there are many other churches which appear
to have given in accordance with their means. It is too
soon to say whether the collection will this year be larger
than last, but it seems probable.

Professor Finlay of Aberdeen read notes at our Clinical
Society of a case of pyopneumothorax in a boy of seven-
teen admitted into the Aberdeen Infirmary with tubercu-
lous pneumothorax on the left side. Resection of ribs
was practised on three occasions, and the lad was treated
for many months in the open air on the balcony of the
ward. He was enabled to resume his work as a gardener,
but there was still a discharging sinus. The tuberculous
process at the right ape.x, which was also present at first,
was arrested, but the urine for some time has contained
albumin, suggesting further operation. Professor Finlay
mentioned another case similarly benefited and one which
had not improved by evacuation of the pus. He thought
radical treatment better than repeated tappings or leaving
the fluid alone, especially in view of the modem treatment
of tuberculosis.

Dr. Parkinson said the late Dr. Fagge had had several
cases of recovery without operation, and asked if it was
desirable to resort to it for so slight a benefit. Dr. P.
Kidd said we should not be too much influenced by the
older methods; the chief difficulty was to determine the
extent of the disease.

The elasticity of the aorta has been the subject of care-
ful research by Drs. Herringham and W. H. Wills, who
have communicated their results to the Medico-Chirurgi-
cal Society as a contribution to the study of arterial
sclerosis. These are some of the conclusions; The
width of the vessel increases with age as the result of
internal pressure; the more it is dilated the less it can
be further stretched; after stretching it returns to its
orig^al volume; elasticity depends chiefly upon the
tunica media and loss of it in changes in the same coat,
and this coat increases in substance \vith age, due to
connective or elastic tissue or both; the muscular tissue
does not seem to vary.

•Dr. Clifford AUbutt expressed general interest in the
subject, and said his owni opinions were corroborated by
the research that a large class of arterial disease was con-
sequent on high blood pressure.

Dr. Auld said that he and the late Professor Coats had
found that in some cases the elastic laminae underwent
granular degeneration confined to the smallest fibers.
Such a change might account for lessened elasticity, and
it would be reinforced by any increase of connective tissue
which would interfere with the elastic fibers.

Dr. Morrison thought there was some muscular hyper-
trophy, and Dr. Finlay hoped the authors would extend
their "researches to the arteries of patients affected with
syphilis and alcoholics.

Dr. Seymour Taylor suggested extending the research
to arteries that are" naturally tortuous. He had thought
that arteries were tortuous from being in movable tissues.
The splenic might be compared with the radial.

Sir D. Powell said widening of the aorta reached its
greatest degree about the age of forty, just when the stress
of life at full pressure begins to tell. CUnically loss of
elasticity of the aorta does not seem to be connected with
cardiac hypertrophy.

A company is being promoted to provide a nursing
home at moderate charges. The existing homes are so
expensive that the middle classes can scarceh' afford to
enter them. They are, too, mostly the appanages of par-
ticular surgeons. "Nor is it only the fixed price per week
that proves deterrent. The extras rival the most sump-
tuous hotels, though without their luxurious appoint-
ments.

The new company has secured the option of a fine block
of buildings in Mandeville Place, an excellent position for
the ptirpose, close to several professional localities. The
proposal is to charge £2 2S. per week for board, lodging,
and nursing. No visiting staff is to be appointed. Pa-
tients will arrange with their own medical men, will only
be admitted on the recommendation of their usual attend-
ants. There will be a house surgeon on the premises foi"
emergencies and to carry out the treatment of patient's
own doctors.

Among the exhibits at the University Converzasione a
loan collection of cats excited considerable attention.
They were passing their time under chloroform. Dr.
Waller, F.R.S., on the program, remarked that "the
accidental deaths under chloroform used for surgical anaes-
thesics are principally due to fluctuations in the chloro-
form percentage. The cats exhibited are spending the
evening under one per cent, of chloroform and air pumped
into the bell-jar by a Dubois pump, which is occasionally
turned to keep up the supply. The cats are to return
intact to their homes."

One lady visitor was overheard to say "what dreadful
headachesthe poor things will have to-morrow." I com-
mend the remark to the antivivisectionists.

Sir Oliver Lodge has given offence in some quarters by
remarking in a review that certain ideas cannot be made
"so childishly simple as to be apprehended by the general
average of so-called educated men in this country, whose
sense-perceptions in the direction of great and compre-
hensive ideas have not been developed." It is rather a
hard saving, but I do not suppose he meant it to be offen-
.sive, though his critics are not slow to retort that the atti-
tude of scientific men is too often one of contempt for
others, and is responsible for much of the indifference of
ordinary educated persons to their work. One admits
there is insufficient appreciation of science, but adds there
is also a "very marked absence of those great expositors
of science who have forced their discoveries and theories
on the attention of the so-called educated men of their
time." This Roland for an Oliver is not undeserved in
the light of the proceedings of the late meeting of the
International Association of Scientific Societies and Acad-
emies, which at its first meeting resolved to exclude the
press.

What is brandy? That question meets us just now in
many newspapers and circulars. It was started by a
prosecution of a person for selling as such a liquid con-
taining 60 per cent, of spirit not obtained from the grape.
Analysts have usually been willing to certify as genuine
any spirituous liquor of a certain alcohoHc strength, but
now the origin of the alcohol is to be taken into account.
The magistrate accepted the definition of the pharmaco-
poeia. The medical value of brandy is thought by many
to depend on the ethers, but others think it does not differ
from whiskey or other spirits, and they attribute all the
effects of all these liquors to the amount of alcohol in
them. It can certainly be plausibly argued that the alco-
hol must overshadow the small amount of ethers. In the
Oliver-Sharpey lectures lately delivered by Dr. Oliver, he
mentioned that the effect of alcohol on the blood pressure
is modified by other constituents of wines, etc. The rnag-
istrate's decision on the case cited has set the advertising
wine and spirit dealers to work with circulars, etc. From
the agents of one I have received no less than twelve cir-
culars, besides as many letters. It seems an extravagant
wav of advertising.

Brigade-Surgeon W. F. Colliott, late of the Royal Army
Medic"al Corps, died on the 8th inst., aged si.xty-five. He
entered the armv in 1S62. had charge of the cholera camp
in India in 1S67, served in the Afghan war 1S78-80, for
which he held the medal. Retired in 1899.

Surgeon-General W. Thorn, I. M. S., died in his eighty-
fifth year on the 12th inst. He retired in 1S77.

July 9. 1904]

MEDICAL RECORD.

Richard J. Dcardcn, J. P., of Manchester, died on the
nth, only forty-nine, from blood-poisoning following ex-
tensive cellulitis contracted at a post-mortem, which he
undertook for a friend, and which within a week brought
him to his death. He took the M.R.C.S. in 1879 and became
House Surgeon at the Royal Infirmary and soon after
entered private practice. He was divisional surgeon to
the Manchester Police.

OUR VIENNA LETTER.

(From Our Special Correspondent.)

OBSTETRIC P.^RALYSIS COMBINED GR.^VES' DISE.\SE .\ND

ADDISON'S DISEASE FUNCTION OF THE PARATHYROID

GLANDS SIG.VIFICANCE OF BLOOD IN THE STOOLS

EXSECTION OF THE TRACHEA FOR CANCER OF THE

THYROID KOCHENEGG IN THE CHAIR OF SURGERY

A CHAIR OF RADIOLOGY.

ViENN.\, June 10. 1004.
At a recent meeting of the Pediatric Society, Dr. Zappert
presented a two-year-old child with bilateral obstetric
paralysis. At the age of six months there was paralysis
affecting the deltoid, biceps, supraspinatus, and prachialis
anticus. The finger movements were free, but the arms
hung powerless, were rotated inward, could not be raised,
and movements of the elbow-joints were impossible.
Under massage and faradization, the paralysis gradually
disappeared, imtil at present there remain only an inward
rotation and an atrophy of the deltoid. The case is
worthy of note because a bilateral obstetric paralysis
very rarely occurs.

In the Society of Psychology and Neurology, Dr.
Hirschl presented a case which gave the symptoms both
of Graves' disease and of Addison's disease. The patient
was a brewer, thirty-six years old, who had been ill since
August, 1903. and who first came to the clinic in the follow-
ing November. Tremor, excessive sweating, and diar-
rhoea marked the onset. .'\t the beginning of October,
the patient noticed exophthalmos, and complained also of
palpitation. The most noticeable symptom was extreme
emaciation. From the middle of August to the 23d of
November his weight fell from 90 to 58 kilos (198 to 128
pounds). Along with the emaciation, went a high grade of
motor weakness and progressive excitability. At the
beginning of October, bronzing of the skin began, which
reached its height at the time of the man's first appearance
at the clinic. JExamination then showed, on the one hand,
loss of motor power, bronzing of the skin but with no
pigmentation of the mouth, excitability and forgetfulness ;
on the other, struma, exophthalmos with the three eye
symptoms, palpitation, and tremor. His weight was
58 kilos (12S pounds); blood pressure, according to the
tonometer. 100; microscopical blood examination normal ;
hsmoglobin, according to the von Fleischl haemoglo-
binometer, 70 per cent.; and glycosuria. At the be-
ginning he had vomited excessively, and later had had
diarrhcea. There were no physical signs of tuberculosis in
the patient, but his mother and first wife had died of
tuberculosis.

Dr. Pineles has made known some recent discoveries
in regard to the physiologj' and pathology of the thyroid
gland and the parathyroids. The fact that after opera-
tions on the thyroid in which the parathyroids are left,
no tetany ensues, while after total thyroid extirpation,
including the parathyroids, tetany is the rule, makes
the assumption natural that there is a causal relation
between the removal of the parathyroids and the de-
velopment of tetany. Experiments on animals.namely
monkeys and cats, have confirmed this opinion. These
experiments showed that total thyroid extirpation,
or the removal of the parathyroids alone, is followed by
tetany, while the removal of the thyroid, the para-
thyroids being retained, leads indeed to cachexia, but
not to tetany. The results of operations on man are
also confirmatory. After extirpation of a tongue tumor
which had developed from a thyroid displaced upward,
tetany did not follow, because the parathyroids, de-
rived from the third and fourth branchial clefts, re-
mained, and were not extirpated. In like manner
tetany occurs less often after resection of the isthmus
than after that of both lobes, because the parathyroids
in the capsules of the lobes remain.

In the General Medical Society, Dr. A. Loebl spoke
concerning a new way of detecting the presence of blood
in the ffeces, and of its diagnostic significance. Loebl
proved its presence in the following way: First, the stool
was examined in its original condition for fat; if it con-
tained much fat, this was next extracted with ether;
the remainder, or the stool not rich in fat, was set aside
with acetic acid vmtil it was of the consistency of thick
soup, or, in the case of a hard stool, a little concentrated
acid was added. To 3 c.c. of this mi.xture was added
an equal quantity of ether, and the whole allowed to stand
for twentv-four hours. The extract was then di\-ided

in two parts of 3 c.c. each; to the first was added freshly
prepared tincture of guaiacum (a solution of guaiacum in
ether), to the second, a solution of Barbadoes aloes in
60 per cent, alcohol, and, finally, to each, peroxide of
hydrogen. After a minute, the" portion with the tinc-
ture of guaiacum becomes blue, the color disappearing
after about fifteen minutes; in the second portion, the
color appears later, but is permanent. Dr. Loebl has,
by this method, examined the stools of 115 patients.
The stools of twenty patients with tuberculosis of the
lungs, who came to autopsy, were examined during life
for the presence of tubercle bacilli and tor blood; nine
cases showed ulcers of the intestine at autopsy, and of
these, six showed tubercle bacilli and blood in the faeces
during life, and three either one or the other: of the
remaining eleven cases, examination had shown tubercle
bacilli in seven, and neither bacilli nor blood in four.

The presence of tubercle bacilli and blood in the fjeces
is diagnostic of intestinal tuberculosis. In the case of a
patient who suffered from gastric ulcer during the attacks
of epigrastric pain, blood was continually found in the
stools, and because of the persistence of this symptom,
the ulcer was closed. The operation confirmed the diag-
nosis. In typhoid fever, by the above method, slight
bleeding could be detected, and, by the adoption of ade-
quate measures, a greater hemorrhage could be stopped
Further, blood has been found in the faeces in cas.s
of intestinal parasites, tetany from autointoxication,
and in two cases of cholelithiasis. Prof. Arthur Schiff
stated in the discussion which followed that, according
to the investigations of Boas and Hartmann, concerning
the appearance of blood in the faeces, a prescribed diet
must be adhered to. Otherwise blood from flesh food
might be mistaken for hemoiThage from the intestine.
Schiff asked for further information in regard to the pres-
ence of blood in cases of tetan}- and cholelithiasis. Loebl
answered that through very recently published in-
vestigations the fact has been established that no blood
is detected in the faeces after the eating of even very large
quantities of cooked meat. Many of the patients ex-
amined by him were, however, on a milk diet. On the
other hand, after the use of the modem preparations of
iron, blood is found in the faces, while this is not the case
after the use of the official preparations. Blood in the
stools of patients suffering from tetany comes from small
hemorrhages following erosions, and is dependent on
the accompanying catarrh. In cholelithiasis, the vul-
nerability of the vessels is well known, and hemorrhage
readily occurs.

In the Society of Physicians, Professor von Eiselberg
presented a patient who had been operated on for carci-
noma of the thyroid, the operation including circular re-
section of the trachea, followed by suture. The defect
on the anterior wall of the trachea after the sloughing
of the suture was covered by a flap of periosteum taken
from the sternum.

In 1898 a man, forty-four years old, having had trouble
with his neck since his eighth year, was operated on at the
Albert clinic for colloid struma. In 1900 the goiter
returned, and increasing dyspncea drove the patient, m
1902, to the Schrotter clinic, where tracheotomy was
done. Through examination of an excised portion,
diagnosis of adenocarcinoma of the thyroid was made.
At first there was improvement, then the carcinoma in-
creased in size through the trachea to the level of the
fistula, when again extreme dyspnoea appeared. In
January, 1904, tiie patient was admitted to the surgical
clinic, and a large, hard, swollen thyroid was found,
holding the trachea in its grasp. On January 11, 1904,
Professor von Eiselberg undertook the extirpation of the
tumor, for which it was necessary to resect 4 cm. of
the trachea. Circular suture followed, after the in-
sertion of a cannula. The stitches sloughed in the
anterior half, and the defect was first covered provision-
ally with a celluloid plate, and afterward with a flap of
peinosteum from the sternum. This required two sit-
tings, the first, Februarj- 19, and the second, March 5.
A small endolarvngeal "mass of granulation tissue was
aftersvard removed at the Schrotter clinic. Thus,
through combination of the ideal methods, resection
and suture, a good result was obtained.

On May 13 Professor Hochenegg took charge of the
Gussenbauer surgical clinic, which has won so high a
reputation through his predecessor. Billroth. Hochenegg,
who, as a pupil of Professor Albert stands in known
opposition to the teachings of Billroth, at his inaugura-
tion for which had gathered all the surgeons and almost
the whole Vienna faculty, honoring his predecessor,
called to mind and commended the service he had done
to surgery. Hochenegg's address related to the treat-
ment and transmission of carcinomata, the topic which
up to the present time has formed a large part of the study
of this clinic.

Another event of this month was the establishment of a

MEDICAL RECORD.

[July 9, 1904

chair of radiology, the first on this continent. It is
occupied by Dr. Kienbock, Dr. Freund. and Dr. Holz-
knecht, and their appointments were confirmed by the
Emperor. All three have worked as pioneers in Austria,
on the subject of radiology, and it remains now to be
seen into what this yoimgest branch of our science will
develop.

THE PRESENT STATUS OF THE SURGICAL
TREATMENT OF CHRONIC BRIGHT'S
DISEASE.

To THE Editor of the Medical Record:
Sir: In your issue of July 2, 1904, appears a letter from
Dr. Edebohls, bearing upon my article, "The Present
Status of the Surgical Treatment of Chronic Bright's
Disease." I hesitated to answer this communication,
the tone of which warrants the belief that the writer
considered my contribution to this interesting subject
as a criticism of his views and practices, while in reality
its prime and sole object was to develop and establish the
indications for, and the limitations of, the rational em-
ployment of surgical therapy in cases of chronic nephritis.
Dr. Edebohls emphatically states in his letter that
his patient, Mrs. C. B., whose history I quoted in ab-
stract in my paper, suffered from chronic parenchymatous
nephritis, upon which a bilateral py clone phr His with miliary
abscesses was engrafted, whereas I claimed that the kid-
neys of this patient presented simply the lesions of a
baeterial (or septic) -nephritis.

Here are the pathologist's reports (page 967): "Right
Kidney. — The large right kidney, riddled with innimiorable
abscesses and with its pelvis filled with pus, showed, on
microscopical examination, typical, histological char-
acteristics of multiple abscesses. In the abscess areas
there was found a thick bacillus corresponding morpho-
logically to a species of the proteus, a class frequently re-
sponsible for suppurative nephritis." Left Kidney. —
There is no description of its gross appearance, but micro-
scopical examination of the small piece of renal tissue re-
moved from the kidney showed "decided histological evi-
dence of multiple foci of nephritis of infectious (septic) type.
As far as was possible to determine from the minute size
of the cortical issue received, these foci were confined to the
areas corresponding to terminal arteries and consequently
had a wedge-shaped outline. In the diseased areas, the
tubules presented granular and partially disintegrated
epithelia, often detached from the mernbrana propria,
and the lumina were not infrequently occluded by polj'-
nuclear leucocytes (pus), fragmented epithelia' blood
cells, and amorphous detritus. Some tubules were filled
with dense hj-aline material (casts)."

Where in these reports are the gross or microscopical
evidences of chronic parenchymatous nephritis? Was I
not right in my statement that these kidneys showed only
the lesions of infectious (bacterial) nephritis? Our
criterion in these cases is the pathological findings, and
from these I drew my conclusions. Upon what evidences
does Dr. Edebohls base his diagnosis of chronic paren-
chymatous nephritis in addition to the infectious (bac-
terial) nephritis?

As to my statement that Mrs. C. B. "finally [suc-
cumbed to the disease," I regret exceedingly that in
arranging the material which was to be employed in my
paper, this patient was recorded as having died. Such
errors are bound to occur in handling so large a number
of cases from the hterature, especially when the patient's
final outcome must be sought for in different numbers of
the medical papers. But while this patient's recovery
is most happy for herself and friends, and most important
for Dr. Edebohls' statistics, it has no significance at all as
regards the arguments in my paper. I consider this
cascasoneof bacterial nephritis, and concerning the value
of surgical therapy in this type of chronic nephritis, I
stated on page 996: "The bacterial nephritides of chronic
character are at times favorably influenced bv operation."
Of Rovsing's eight cases, seven were cured "and one was
improved.

It is thus seen that recovery in the bacterial form of
chronic nephritis has been the rule, and I am most happy
to learn from the doctor that his patient is so far doing
well, and I regret the error which occurred in the tabula-
tion.

From the above it is evident that the validitv of mv
deductions and conclusions are not nullified bv'the in-
correctness of the premises upon which thev are based
(letter, page 26), but rather show that the studv of this
case before the operation upon the second kidnev was
incomplete, for a culture of the urine of the left or"an drawn
by aseptic ureteral catheterization would probablv have
revealed the infecting organism and so have led to a correct
ante-operative diagnosis.

The incongruity" of the criticism of Dr. Edebohls con-
cerning avoidable errors on my part will appear at once

to him who reads the doctor's writings and reports of
cases and fails to find therein any mention of a system-
atic practice to determine by aseptic ureteral catheteriza-
tion and culture from the urine obtained in this way, the
nature and causation of a chronic nephritis, and who
misses in his publications the routine practice of ex-
perienced kidney surgeons of determining the combined
and individual functional sufficiency or insufficiency of
the kidneys by the absolute scientific means which ureteral
catheterization and cryoscopy have put at our disposal,
before proceeding to operation upon these organs.

A. A. Berg, M.D.
523 M.tDisoN Avenue.

Boston .McJi<:ai and Surgiiai Journal, June 30, 1904.

Anomalies of Thyroid Secretion. — Frederick C. Shat-
tuck gi\es a most interesting paper on the evolution of
our present knowledge of thyroid function, reviewing
step by step the advances that have been made in the
knowledge and treatinent of thyroid affections in recent
years. Whether the action of the thyroid and parathy-
roids is antagonistic, complemental, or unrelated, we
do not yet know. But the evidence so far does not seem
to indicate a vital causal connection between the parathy-
roids and Graves' disease. The whole treatment of
myxcedcma is practically comprised in the administra-
tion of thyroid extract. It is safer to begin with moder-
ate doses, from 3 to 5 grains, twice a day for an adult,
increasing the dose in size, frequency, or both, as the
tolerance of the patient is developed. The treatment
of Graves' disease has long been unsatisfactory' at the
best. The diet should consist mainly of fats, "starches,
and sugars, with great moderation in or abstention from
highly nitrogenous food. Rest and quiet are most ad-
visable. A cool suminer resort is verj- important. The
bowels should be carefully looked after. The bowels
are apt to be either constipated or relaxed. Diarrhcea
may be treated by some form of bismuth. Calomel,
once or twice a week, has been used with success in cases
of constipation. Neutral bromide of quinine has brought
about normal defecation both in cases of diarrhoea and
of constipation. This drug, the writer has found more
helpful than any other he has ever used. The toleration
of quinine in Graves' disease is remarkable, and is seem-
ingly proportional to the severity of the symptoms. If
these measures are not foUow^ed by distinct improvement
operation is to be seriously considered in severe cases.

Journal of the .American Medical .Association. July 2,1904.

Dysentery; A Report of Several Cases in Which Bacillus
Dysenteriae (Shiga) Was Found in Washington, D. C. —
Louise Taylor-Jones concludes that Washington, D. C, is
incKided in the geographical distribution of B. dysentcrice
(Shiga). The Shiga bacillus, both alkaline (Shiga) and
acid (Floxner) types, is found in that city both in adults and
children suffering from dysentery. An alkaline type
found in one case was a slight \'ariation from the type, in
that in three days in glucose agar, not first made sugar-
free, the bacillus produces a slight amount of gas, whereas
no gas is produced with the sugar-free glucose agar. None
of the other Sliiga bacilli at hand produced gas in this
same Tiiedium.

Lumbar Abscess: Report of Six Cases Treated by As-
piration and Injection of lodoform-Glycerin Emulsion. —
Alfred Irving Ludlow made this clinical report and sum-
marized as follows: (i) Four cases gave a family history of
tuberculosis. (2) Five cases occurred in females whose
ages ranged from seven to thirty-nine years and one case
in a male twenty-five years old. (3) Two patients gave
a history of injury to the back. (4) In three cases two
aspirations were made, in one case three, in another four,
and in another ten. (5) The urine from four cases out of
six gave a reaction for iodin the next day after the as-
piration. This reaction persisted only for two or three
days, except in one case in which it persisted for two
weeks. (6) Slight mental depression was noticed in two
cases. (7) As a general rule, there was an elevation of
temperature from two to four degrees following each
aspiration. (S) The cultures were sterile in every case
except one, in which Bacillus proteus vulgar isvca.sohta.\ned.
(9) In all the si.x cases there has been no indication of
return of the abscess after a period of five years in one
case, three years in another and two years in a third,
while in the remaining three, one year or less has elapsed
since the last aspiration. There was a marked improve-
ment in the general health of every patient.

Medical Xeu-s, July 2. 1QC4.
Diagnosis and Treatment of Internal Hemorrhoids. —
H. A. Bray coricludes that (i) In the treatment of internal
hemorrhoids, it is important, in the first place, to de-

July y, 1904]

MEDICAL RECORD.

termine whether the disease is primary or secondary to
some affection of the pelvic organs. (2) In the first stage
of hemorrhoidal disease no operative treatment is in-
dicated. (3) The tnie value of the non-operative treat-
ment is frequently underestimated in the second stage
of hemorrhoidal disease. (4) None but operative treat-
ment should be resorted to in the third stage of hemor-
rhoidal disease.

Primary Myokymia; with Report of a Case. — Robert M.
Daley defines myokymia as a disorder characterized by
fibrillary and wave-like contractions of the individual
fibers of various muscles of the body without locomotor
eflect. Usually it appears as a minor symptom, in
diseases of to.xic origin, such as lead and mercurial poison-
ing. It is also seen in neurasthenia and in sciatica. It
may occur as the only morbid condition. Of the cases
previously reported, all save two, ha\-e been among the
laboring classes. All of these cases were males, the ages
running from twenty-one to seventy-one years. In two,
the legs only were affected; in the remainder, the legs and
arms or legs and entire muscular system, excepting in one
instance, the hands, and in another, the face and neck.
None show atrophy of the muscles or much disturbance of
the general health. Nearly all complain of general pains,
indefinite in character, and also of becoming easily tired.
Four cases were cured and improved by rest, galvanism,
and warm baths. Of the patholo.gy nothing is known.
The writer reports a case of this nature.

A Consideration of the Question of Drainage in Cases of
Acute Appendicitis with Spreading Peritonitis. — Lucius
Wales Hotchkiss believes that he has amply demonstrated
the great value of the smaller incisions, of the location and
removal of the appendi.x largely by the sense of touch,
which does away with over much exposure and handling
of the intestines and of the free irrigation of the peritoneum
with hot normal salt solution, depending upon this rather
than drainage and the removal of the diseased appendix
in every possible case. This practice is a radical depar-
ture from the method formerly employed. The power of
the peritoneum to deal with infection is marvelous. In
acute progressive appendicitis, nature strives to wall off
the diseased organ by a barrier of plastic exudate and
throws out a powerful second line of defense against gen-
eral infection by bringing about marked hyperleucocytosis.
In the case of the gangrenous appendix, however, the
task is, as a rule, too much for the natural physiological
processes to accomplish unaided. The first thing to do is
to remove the focus of infection, the appendix, and to do
it so as not to cripple the inherent power of the peri-
toneum to deal with such toxic products as must neces-
sarily be left behind. The writer states that during the
past few years he has grown to rely almost wholly upon
the flushing of the peritoneal cavitj' with hot normal salt
solution, rather than upon any method of external drain-
age. The writer believes that the drain has practically
been eliminated as a factor of any importance in the
treatment of spreading peritonitis, excepting so far as it
acts as a drain for the e.xtemal wound, which, in most of
these cases is an infected wound and heals by granulation.
The writer agrees with Clark and Norris in their conclu-
sions that the use of salt infusions does not increase, but
minimized the danger of pyogenic infection ; and in ad-
dition to the reduction of mortality, the convalescence of
the patient is rendered infinitely more comfortable and
satisfactory through the reduction of thirst, the increase
in the urinary excretion, and the minimizing of vesical
irritation.

Xew York Medical Journal, July 2, 1904.

X-ray Therapeutics. — G. H. Stover relates fifty-
one cases which in part indicated the main features
of the work being done by the ;i;-ray. Lupus er^-the-
matosus is more slowly amendable to treatment by the
x-ray than are other forms of lupus. So uniform has
been his success in the treatment of epithelioma that
he believes the .t:-ray to be a specific for this condition.
In carcinoma the results have not been so gratifying.
His results in the treatment of bone tuberculosis has
been gratifying. In certain diseased conditions the
effect of the .v-ray was very satisfactory, even brilliant,
yet for a long time to come great caiition should charac-
terize our utterances to patients. He regretted the
rash manner in which many who were totally unfitted
were pushing into i-ray work. He believed that after
a while there was going to be a reaction against the
x-Ta.y as a therapeutic measure, and he hoped the
pendulum would not swing too far, casting undeserved
discredit on a therapeutic agent that has established
a rightful place for itself.

Hermann Brehmer, and the Semi-centennial Cele-
bration of Brehmer's Sanatorium for the Treatment of
Consumptives (July 2, 1854- Ju'y 2, 1904) — S. A. Knopf
believes that a fitting tribute to the fotmder of the

first sanatorium in the world for the exclusive treat-
ment of patients afflicted with pulmonary tuberculosis
and the best known promulgator of modem phthisio-
therapy may well be paid on this occasion from this
side of the Atlantic. Hermann Brehmer was bom
in Kurtsch, Province of Silesia, Pmssia, August 4, 1826.
He attended the Elisabeth Gymnasium in Breslau,
and after receiving his classical degree went to the Vni-
versities of Breslau and Berlin, studying natural phil-
osophy and mathematics. He was so attracted by
the lectures of Johannes Miller, the great physiologist,
that he decided to study medicine instead of mathe-
matics. He began to practise in the little village of
Goerbersdorf which, at that time, had no more than
900 inhabitants. Owing to *he intervention of Hum-
boldt and Schoenlein, he received concession from the
government to build his sanatorium. It had a small
beginning, but its success was marvelous, and to-day
it is the largest private institution of its kind in the
world, and can accommodate about 300 patients. Breh-
mer died December 12, 1889, when the sanatorium
movement was hardly in its infancy. At the time of
his death there were three sanatoria in Germany, while
now there are hundreds. In the United States there
are now 135 institutions already in operation or pro-
jected.

The Results of X-ray Treatment. — Samuel Beres-
ford Childs concludes from his own experience and that
reported by others: First: The therapeutic field of
greatest usefulness of the a--ray is with superficial epi-
theliomata, rodent ulcer, and lupus vulgaris, when the
area involved is conspicuous, as on the face or neck,
and where a cosmetic result is particularly to be desired.
Second: Healing by the i'-ray leaves the smallest
and least perceptible scar; for, when properly applied.
it destroys onlv diseased tissue, and particularly com-
mends itself for use in those localities where it is un-
desirable to sacrifice the surrounding tissues. Third:
The .v-ray is very efficacious in many obstinate cases,
which have resisted the ordinary methods of treatment,
such as acne rosacea, chronic localized patches of eczerna
and psoriasis, lupus erythematosus, and kindred skin
diseases. Fourth: The' results in tuberculosis glands,
when no suppvirating focus is present, are encouragmg
and the enlarged mass of glands in Hodgkin's disease ap-
pear to be susceptible to the treatment. Fifth: The
.i;-ray should not be employed in any operable, deep,
malignant growth, with two exceptions: First: as
pointed out by Coley, where a surgical operation would
sacrifice an extremity, and even in this case the value
of the jc-ray is uncertain, and is determined by a few
weeks' trial. Second, as mentioned by Pusey, with a
view to limiting the operation by checking the growth
when immediate operation is inadvisable. Sixth: The
.r-ray mav be of service even in inoperable malignsnt
growths, by relieving pain, diminishing discharges, and
lessening their offensiveness, and in many cases life
may be prolonged in comparative comfort for a con-
siderable period of time. Furthermore, from these ap-
parently hopeless cases a number of remarkable im-
provements and a few recoveries have been reported.
Seventh: The .-r-ray should be used as a prophylactic
against return after "all operations for the removal of
deep malignant growths. Eighth: The area of ex-
posure should be wide, and the intensity and quality
of the rays should be adapted to each case.
Amcru-an Mcdu~im. July 2, 1904
Measurements of Blood-pressure in Fevers Before,
During, and After the Administration of Strychnine. —
Richard C. Cabot declares that among those cases studied
were 31 of typhoid fever, 4 of pneumonia, and 1 5 others
with a variety of diagnosis. In 3 2 cases the strychnine was
given bv mouth, and in iS subcutaneously. The total
daily dose was usually '/i grain. The measurements
were taken with Stanton's modification of the Riva-
Rocci instrument. The observations extended over
about eight months, and include over 5,000 measurements.
The total result is negative. The writer cannot see that
strychnine exerts any influence upon the blood-pressure
in febrile cases, when given in the manner and dose as
mentioned. In the 24 hours following the administra-
tion of the dmg there was a rise of 5 mm, or more of
pressure in 16 cases, a fall in 17 cases, and no change in
24. The average pressure in the 50 cases that received a
daily dose of strychnine was no greater than in 18 control
cases without any drug. While strychnine and whiskey
seemed to be entirely without influence upon the blood-
pressures, the sight "of the dinner tray or the prospect
of getting- up produced a most obvious, though transient,
rise in the pressure. The writer concludes that in the
dosage used, strvchnine does not raise or in anyway effect
the maximum or minimum blood-pressure so far as can
be determined bj^ the instrument employed.

MEDICAL RECORD.

[July 9, 1904

Tuberculosis As It Affects the Skin. — M. B. Hartzell
declares that the most frequent form of skin disease
due to the tubercle bacillus is lupus vulgaris. It is
possible to demonstrate the presence of bacillus tuber-
culosis in lupus tissue, but this organism is scanty in
numbers. This disease may also effect the nasal, buccal,
laryngeal, and vaginal mucous membranes. "Tubercu-
losis verrucosa cutis" is closely related to lupus vulgaris
in some of its features. Identical with verrucose tuber-
culosis is the so-called anatomic wart, verruca necro-
genica. One of the earliest recognized forms of tuber-
culous affections of the skin is the tuberculous ulcer,
known also as miliary tuberculosis of the skin. It is
usually found about the orifices of the body, and is in
the great majority of cases secondary to tuberculosis
of other organs. It may, however, occur upon other
parts, and it may occur as a primary lesion, and be fol-
lowed by visceral tuberculosis. Scrofula is but a mani-
festation of tuberculosis. It gives rise to a n\imber of
skin lesions, usually ulcerative, to which the name scrof-
uloderms has been given. The commonest form of
scrofuloderm is the chronic ulcer which occurs so often
in connection with tuberculous adenitis, especially in
the region of the neck. In all of these affections, the
presence of bacillus tuberculosis has been demonstrated
^•ith more or less certainty. Another class of eruptions
is seen in individuals who either in themselves or m the
memljers of their families show a more or less clear his-
tory of tuberculosis, but in which all efforts to find the
tuberculous organism have failed, although the tissue
changes are such as are present in tuberculous disease.
The constitutional treatment of tuberculosis of the skin
differs in no respect from that of tuberculosis of other
tissues.

The More Remote Consequences of Infectious Bile.

— John B. Deaver calls special attention to these three
conditions — pancreatitis, biliary cirrhosis, and adhesions
of the gall-bladder to various of the surrounding vis-
cera. Seventeen cases of acute pancreatitis ha\-e been
reported, eleven of which were accompanied by calculi
in the biliary tract. A considerable number of cases
do occur, however, in which gallstones are absent, and
should be carefully studied, for gallstones do not always
induce acute pancreatitis. Especially must the infer-
ence of microorganisms be considered as causative fac-
tors in obstructing the pancreatic ducts. Bacteria may
not only infect the retained secretion, but may also by
direct continuity ascend from an existing gastrointes-
tinal cataiTh. Chronic pancreatitis is also often due to
sorne obstruction of the duct of the pancreas by gallstones.
This is especially striking when the biliary' calculus is
large, and so situated that the duct of Wirsuiig is occluded
without the entrance of the bile into the pancreas. The
diagnosis of pancreatitis is often very difficult. In gen-
eral, when an individual from whom the history of a
previous gallstone colic may or may not be elicited, is
suddenly seized with severe epigastric pain, nausea,
vomiting, rapid pulse, dyspnoea, and cyanosis, fol-
lowed by a rapid loss of strength, the "diagnosis is
acut« pancreatitis. The early symptoms strongly
resernble those of intestinal o'bstruction, and the ex-
haustion and collapse are often so severe as to induce
death within forty-eight hours. The pain is colicky
in character. Chronic pancreatitis, due to gallstones, is
often hard to recognize. It is only by grouping both
the clinical and the laboratory findings that the disease
of the pancreas may be accurately and satisfactorily
studied. As to biliary cirrhosis, the writer states that
in the great majority of common-duct obstruction cases
for which he has operated, a bacteriologic in\-estigation
of the bile has revealed the presence of some microorgan-
isms, the colon bacillus, the typhoid bacillus, the staphy-
lococcus, or the streptococcus." He belie\es that as com-
plete bile stasis rarely occurs in common-duct obstruc-
tion, infection must exert a positive influence in the
cirrhosis. Adhesion of the gall-bladder or ducts to sur-
rounding viscera will follow nearly all severe inflammations
of the gall-bladder from a pericholecystitis and embar-
rass the functions of the contiguous organs involved by
the adhesions. The typhoid bacillus is a most fertile
factor in the production of acute or chronic biliary tract
disease, or in the causation of gallstones. But the first
place in the r61e of gallstone producer must be credited
to the colon bacillus. The entrance of bacteria into the
biliary tract is possible by three wavs : Thev may ascend
the bile ducts from the duodenum," are dep"osited by the
general circulation, or reach the ducts and gall-bladder
by means of the portal vein.

The Lancet, June 25, 1004.
Notes on Three Cases of Intestinal Obstruction. — G.
Reinhardt Anderson makes a record of three cases of

intestinal obstruction which were instructive as the)' illus-
trated the necessity of caution before expressing an opin-
ion on conditions leading to the obstruction. The first
case was one with an vmsuspected obturator hernia occur-
ring in an elderly woman. In the second the small intes-
tines were so matted together that obstruction, which had
been incomplete for some time, became suddenly complete,
and for this condition lateral anastomosis had to be per-
formed. The last case was one of chronic obstruction due
to inflammatory exudation in the pelvis, necessitating a
temporary colotomy for its relief.

A Case of Mania from Traumatic Meningitis; Recovery
after Trephining. — Charles Brook reports the case of a
man. twenty years old. who struck his forehead violentl)'
on the bottom when diving. He was not rendered uncon-
scious, but went home complaining a little of his head.
His manner changed from that day and he became irrita-
ble and excitable and within one month had paroxysms
of violence. Six months later he was placed in an asylum.
Six weeks later Dr. Brooks saw him and found a distinct
swelling on the right frontal bone, rather red and some-
what tender. Trephining was advised and performed.
The bone was rather thin and very hard and white, with
no diploe. The dura was opened and three ounces of clear
serum let out. The wound healed perfectly. Never from
the time the patient reco\ered consciousness has he shown
the slightest sign of mental disturbance.

The Prophylactic Use of Morphine in Cases of Severe
Cerebral Injury. — J. A MacDougall, in 1890, when he read
a paper on "Meningitis," by Dr. Barr of Liverpool, real-
ized how freely morphine might be given in this disease,
how excellent were the results attendant upon its employ-
ment, and how in all probability its beneficial action was
brought about largely through its effect upon the vascular
and ner\-ous systems, inducing that condition of rest.
Further and natural reasoning was this: if opium by its
action on the nervous system quiets brain cells and lessens
the functional activity of the nervous fibrils which connect
them ■R'ith one another, if it lessens pain and removes the
effect of peripheral stimuli, if it contracts cerebi;3l arteri-
oles and through the cardiac ganglia renders the heart's
action slower and vascular pressure less pronounced, then
its effect upon a brain that is traumatically damaged and
that demands quiet for its repair can only be beneficent.
He had found that if after severe brain injury the patient
was kept under the influence of morphine convalescence
was more rapid and steady, grave cerebral symptoms had
been wanting, and the continuous rise of temperature had
been notably absent. A short record of cases was given
to strengthen his contention.

British Medical Journal, June 25, 1904.

Hypodermic Injection of Quinine Sulphate. — G. F.

Darker finds that ordinary quinine sulphate mi.\ed with
about one and one-half times its own weight of vaselin
makes a .suitable mixture to inject under the skin of the
natives in \\est Africa to lessen the malarial index. A
mass containing 15 to 20 gr. of quinine after injection
takes about three and one-half months to absorb. During
that time the writer has failed to find malarial parasites
in the children on whom he has tried this mixture. An
ordinary metal hypodermic syringe will suffice. The
whole proceeding must be done under asejitic precautions.
It is well to give at the same time a dose of quinine by
mouth or an intramuscular injection of the same drug.
The left side of the abdomen near the fiank is the most
suitable site for injection.

Acute Dermatitis Produced by Satin-wood Irritation. —
H. E. Jones gives an account of two distinct outbreaks of
acute dermatitis occurring among a number of joiners and
cabinet-makers. The exposed parts are those affected.
The first thing noticed is an irritation on the skin; later
on the parts become hot and red, and subsequently be-
come swollen and uncomfortable, and although not painful,
the patient cannot sleep well. Still later the parts be-
come moist and complete desquamation takes place. The
first attack is rather slow in its onset, but relapses come
on with great rapidity. After desquamation, the new
skin would be more easily irritated than the old. The
cause of this dermatitis seems to be irritation caused by
East Indian satin-wood dust. .>\s to treatment, it ha!s
been suggested that the men should remain off duty till
the epidermis is fairly strong, and that then vaselin or
some oily substance be smeared over the exposed parts
while the men are at work.

Intrauterine Infection of the Foetus in Smallpox. —

James M. Cowie and Duncan Forbes speak of three cases
they have seen of infants attacked with smallpox so soon
after birth as to warrant the conclusion that they recei\-ed
the Infection while still in utero. Considering the interval
between infection and the appearance of the rash as the

July 9, 1904]

MEDICAL RECORD.

usual one of fotirteen days, the first child must have been
infected on or about the date of onset of the mother's
illness and three or four days before birth; in the second
case the time must have been six days before the onset in
the mother and seven days before birth, and in the third
case five days before the mother sickened and seven days
before birth. These children were all born about full
time. Two other cases are mentioned by the writers:
One was tliat of a woman in the seventh month of preg-
nancy who developed a discrete attack of smallpox. She
was discharged from the hospital about a month after
admission. The child was bom about a month after
discharge and showed no signs of having had smallpox.
It was successfully vaccinated. Thus, no immunity was
conferred on the child by the mother's attack. The other,
a five-months fixtus bom in the fourth week of the mother's
illness, showed no signs of smallpox. The liability of the
fietus to smallpo.x appears to increase directly with its
age.

Deutsche mcdizinischc Wochenschrifl, June 16, 1904.

Therapy and Prophylaxis of Chronic Malaria. — Bassenge
reports two cases contracted in the tropics, in which the
continued administration of quinine was without effect
in inhibiting the attacks or in preventing their recurrence.
One patient had taken a half gram every fourth day for
almost a year as a prophylactic measure, and yet became
infected with malaria, the parasite of which could be
demonstrated in the blood with certainty after the reac-
tion following the injection of tuberculin. In the other
patient the prophylaxis was also inefficient and the quinine
given subsequently had no effect. A blood examination
had never been made and the type of fever was unknown .
After this had been determined by careful examination
to be of the quartan type and the quinine administered
at the proper moment, the disease was cured. This
shows the necessity of knowing exactly when to give the
quinine, as in this case the drug had no effect, and brought
on, moreover, an obscure series of nervous symptoms.
Unless the microscopical examination is made, therefore,
the ordinary clinical diagnosis of malaria is of little value

Late Recurrences of Carcinoma. — ^Jordan believes that
the question of complete recovery from carcinoma can
only be determined after the lapse of another twenty or
thirty years, when a series of observations are available
which have extended over several decades. The reports
of isolated cases which have remained free from recur-
rences for prolonged periods are not always conclusive,
for, as the author's observations show, late recurrences
even after fifteen years, are not imcommon. He claims
that one of the main factors in determining recurrences
is in the individual character of the growth, and this
varies within wide limits. The first case which he reports
is a carcinoma of the tongue, where a recurrence took
place after nineteen years after complete operative
extirpation. The lymphatics were not involved at
either time, which may be taken as an indication of the
more or less benign character of the growth. The other
case was a mammary carcinoma which ran a chronic course
and showed recurrences every few years for fifteen years.
It seems that this also was a mild form of the tumor,
with diminished proliferative energy, so that minute par-
ticles remaining occupied several years before attaining
the size of a palpable nodule. The author thinks that
the statistics thus far presented be subjected to a revision
with this point in view, i.e. the late recurrences, it will
be found that so-called cases of complete cure are merely
cases with prolonged freedom rather than total freedom
from recurrences. It is also necessary to distinguish
between the tumors which recur rapidly and those which
recur after the lapse of a longer period.

A Substitute for Both Ureters. — James Israel calls at-
tention to a class of cases in which a congenital obstruction
to the urinary flow may be followed by a hydronephrosis
which may gradually attain a considerable size withotit
the production of any symptoms, and then suddenly
manifest its presence by the development of a severe acvite
illness. This may take the form of cohc, due to the in-
creasing tension in the sac, or of septic fever and renal
pain, due to an acute infection of its contents. Both of
these conditions were well marked in the author's case,
in which, in a thirteen-year-old boy, there was a large hy-
dronephrosis in each kidney due to congenital disturbances,
which was not detected xmtil colic on the right side, and
an acute infection of the sac on the left side, led to the
discover}' of the true state of affairs. Operation was first
done for the condition on the left side, and hei^e the
hydronephrosis was foimd to have been caused by a con-
genital displacement of the kidney, and it w-as determined
to secure better urinary drainage by shifting the origin of
the ureter to the lowest point of the renal pelvis. This
was accomplished by shortening the blind pouch by

making a longitudinal incision and then suturing it in
a horizontal direction. The procedure failed, however,
in producing any more perfect drainage, and a few days
later renal puncture was resorted to in order to relieve
the symptoms. Soon after infection of the left kidney
took place, which was then communicated to the right.
Every known method was tried in attempting to relieve
the patient and restore the normal passage between
kidney and bladder, but -without success. It was then
decided to secure this end without the medium of the
ureter, and a fistulotis communication was devised
between the bladder and the pelvis of the kidneys with
the aid of a system of tvibes, similar to what had Ijeen
done in another patient with a solitary renal fistula
(described in Deutsche medizinische Wochenschrijt, 1903,
No. i). The appliance had been in good working order
for over a year and the boy is in good general health.
Twice a week the tubes are changed and the bladder and
pelvis irrigated with boric acid solution. Notwithstand-
ing the success of this procedure, the author still hopes
to arrive at the same result bj* doing a resection of the
ureter and implanting the same in the most dependent
portion of the renal pelvis, which after the obstructions
have been removed can be made smaller and will remain
thus .

Berliner klinische Wochenschrijt, June 13, 1904.
Gonorrhoea! Stomatitis in Adults. — Jurgens believes
that this process not only has a distinctive etiology, but
also presents a distinct clinical picture. The patient,
in the case which is reported, shortly after the appearance
of a gonorrhrcal urethritis, developed a diffuse inflamma-
tion of the mucous membranes of the gums and the cheeks.
These were covered with a dirty gray membrane, which
could be readily wiped away, but there was ulceration.
In smear preparations the gonococcus was identified with
difficulty, but better success was had with cultural tests.

M iinchencr inedizinische Wochenschrijt. June 14, 1904.

Operations Conducted Alternately by Daylight and the
X-rays. — Grasey has devised an apparatus by which
it is possible to operate with both of these sources of light
as when looking for a foreign body imbedded in the
tissues, such as a needle. The apparatus is so con-
structed that one eye of the operator may be employed
in looking at the .r-ray picture, while the other is engaged
in following the steps in the operation on the part under
treatment. The principle involved is like that in a camera
lucida such as may be attached to a microscope for draw-
ing purposes.

A Case of Trypanosome Disease in Man. — Gunther and
Weber report a case of this tropical disease, which is ap-
parently the first observed on the continent of Europe.
The patient had been in South Africa and returned to
Europe, where he became afl3icted with what at first
thought to be malaria. The main points in the history,
which is reported in great detail, are as follows: the
chronic course of the complaint extending over two j^ears,
recurrent irregular attacks of fever, loss of strength and
decrease in the haemoglobin, locaUzed transitory a-demas,
pecuHar erythematous eruptions, enlargement of spleen
and liver, which was more marked during the acute ex-
acerbations, slow pulse and occasional dyspnoea, com-
bined with abnormal irritability of the circulatory system.
In addition there appeared an inflammatory process on
the leg resembling the early stages of a phlegmon. As in
the other cases reported, it was possible to demonstrate
the presence of the trvpanosomes in the blood during the
attacks of fever. A "further communication is promised
on the results of treatment given.

Diagnosis of Typhoid Fever. — Roily reports on the re-
sults of his observations with Schottmuller's method, by
which the typhoid bacilli can be demonstrated in the
patient's blood. By the aid of a syringe, 20 c.c. of blood
are abstracted from" one of the arm veins and rnixed with
glvcerin agar at a temperature of 42° to 45' C. This is
po'ured out in Petri dishes placed in an incubator for
one or two days, and then examined. In fifty cases of
typhoid subjected to this test cultures of the specific
bacillus were obtained in 44; i.e. in 88 per cent. The
number of colonies varies within w-ide limits, but it
seemed that the larger numbers were associated with the
early stages and the height of the disease. In sixteen
cases it was found that during the earlv days of the
disease the agglutination tests were negative, while the
bacilli could be demonstrated in the blood, and as doubts
of the true conditions usually exist during the first day
such a method of diagnosis ought to prove of exceptional
value. In general practice it is somewhat difficult to
carrv out this procedure and the writer proposes certain
modifications. As it is necessary to keep the blood
fluid, he advises mixing the blood as soon as it is ab-

7°

MEDICAL RECORD.

[July 9, 1904

stracted with 20 c.c. of a solution made up of peptone
5 gm.; grape sugar, 50 gm.. in 100 c.c. of water. This
IS boiled from five to ten minutes. Blood to which this
solution has been added remains fluid for a day, and can,
therefore, be transported to a place where the proper
laboratory facilities are obtainable. It was also sought
to improve on the agglutination tests by substituting
for the cultures of living bacilli a fluid in which the dead
bacilli could be held in suspension. This was accom-
plished by killing the typhoid bacilli in a bouillon cul-
ture with formol. Experiment showed that agglutination
takes place in the same dilutions, with the bouillon con-
taining the dead, a.s that containing the living bacilli.
Blood serum which failed to agglutinate the one also failed
in the case of the other. In the case of the dead culture,
agglutination takes place about fifteen to thirty minutes
later, but is evident on either micro- or macroscopical
examination. The bouillon containing the dead bacilli
may be kept for considerable periods and still retain its
efficienc}-.

French and Italian Journals.

Influence of the Soil on the Virulence of the Vibrio of
Cholera. — A. Paladino-Blandini made cultures of the
vibrio of cholera in dry earth, in moist earth free from
organic matter, and in earth that was impregnated with
fecal matter. In dry earth the virulence was decreased;
in moist earth it was less rapidly diminished; in earth
impregnated with a considerable amount of organic matter
its virulence was increased. But if between two periods
of remaining in the earth it passed through the body of
an animal, its virulence was very markedly increased.
Both its presence in the earth and in the animal were
important factors in the increase of virulence. There
seems to be a coincidence between the presence of the
vibrio in the deepest levels of the subterreanean water,
where the sun does not reach, and the coming of a severe
epidemic of cholera. — Giornale Internationale delle Scicnze
Mediche, May 15. 1904.

Chorea in Pregnancy. — Vallois reports the case of a
woman of twenty-si.x years, a primipara, who toward the
end of the eighth month began to exhibitjslight arrhythmi-
cal movements in the arms, and certain psychic disturb-
ances. These movements increased till the whole body
was involved. The child was bom, but the cerebral
troubles persisted. The patient had auditory hallucina-
tions, and thought she heard voices calling her name.
There was anaesthesia of the conjunctiva and of the
pharynx, but no cutaneous an.-esthesia. Then the choreic
movements began to disappear, and instead of the
phenomena of excitement, those of depression succeeded.
The patient was badly nourished and became emaciated.
Since labor there had been no rise of temperature. The
pulse, which remained for a long time 104 to 112, rose
finally to 132. The mental troubles grew wor.se. and the
patient was sent to an asylum. This case is like most
of its kind. The chorea is of an hysterical nature and not
rheumatic. — LaMedecine Moderne, June 8, 1904.

Laryngeal Syphilis. — A. Ohauffard and Paul VioIIet
discuss this subject and present the history of several
patients. They call attention to the predominance of
nocturnal symptoms. A chill often ushers in the acute
phenomena of syphilis. It is sometimes very difficult to
differentiate syphilitic laryngitis from cancer, sarcoma,
lupus of the larynx, and laryngeal tuberculosis. Ordi-
narily syphilitic infiltrations are indolent .while the ulcera-
tions have a relatively rapid evolution. Cancer has a
tendency to vegetate first, it is complicated v.-ith adenitis
and its evolution is in general far more slow. In lupus
there is generally noted the process of spontaneous
cicatrization side by side with active lesions. The evolu-
tion of these lesions is still slower than in the case of
laryngeal tuberculosis. The latter often presents the
manipulations of acute or chronic cedema which are seldom
seen m syphilis. The epiglottis is often attacked by the
latter, while the arytenoids, especially, are attacked in
tuberculosis. Finally, syphilis is not accompanied by
concomitant pulmonary symptoms. The possible com-
bination of syphilis with cancer or tuberculosis must be
remembered. Syphilitic lesions capable of affecting the
larj-nx and of givmg the laryngoscopical image of paraly-
sis are very varied. In order to establish a'diagnosis of
syphilitic laryngeal affections, a general examiriation of
the patient must be made including an exploration of the
ganglia of the neck, the lungs, the aorta, the thorax and
Its contents, the reflexes and the entire nervous system.
Lumbar puncture is sometimes helpful in cases of sus-
pected tabes. Laryngoscopical examination is most im-
portant. — Gazette des Hdpitaux Civils et Militaires, Time
0, 1904.

Annals of Surgery, June, 1904.

Sarcoma of the Tongue.— C. B. Keenan finds only
about three dozen cases of this nature on record. He

adds one personal case The patient was unwilling to
undergo a radical operation though various portions
of the tumor, in fact, almost all of it, was removed. He
died some months later from recurrence in the abdomen,
but examination at this time showed no signs of re-
currence in the tongue. The author then gi\-es a synop-
sis of the recorded cases. Analysis shows that they
were all of the round-celled variety. The majority of
them occurred between the fortieth and fiftieth year.
Extensive metastases were the rule. Generally the
growth was slow. They are distinguished from can-
cerous growths by the fact that the epithelium usually
remains intact or ulcerates only after a long period.
From gummata they are distinguished by the thera-
peutic test. Under the microscope, however, it is not al-
ways easy to distinguish a gumma from small-celled
sarcoma. Wide excision is the only rational therapy.

Revival of Suprapubic Prostatectomy. — The object
of the article of F. D. Gray is to call attention to the
views of Freyer, whose work the author has been able
to follow by personal observation. Freyer contends
that a certain class of enlarged prostates, notably the
large cedematous type, which he considers more com-
mon than do other authorities, can most safely and
easily be reached by the suprapubic route with perfect
restoration of bladder ftmction and with a very small
mortality. His method is one of enucleation through
the upper route. His procedure is based on the work
of Sir Henry Thompson, who taught that the prostate
has a thin, closely adherent, fibrous covering, dipping
between the lobes of the gland, and from which it cannot
be enucleated; also that outside this capsule is another
covering (which Freyer terms the sheath), in reality the
layers of the rectovesical fascia, between which and the
capsule is a natural "line of cleavage." Freyer's com-
parison of the prostate capsule, and sheath to an orange,
with its closely adherent inner skin which dips between
the various sections and is surrounded by the rind, from
which it is readily enucleated, most perfectly conveys
the anatomical idea on which his suprapubic enucle-
ation is based. He calls attention to the fact that
in fetal life the prostate is double — two lateral halves —
and that later they are only united by the upper and
lower borders, thus enclosing the urethra, while in the
advanced adenomatous enlargement these connections,
especially the upper, easily give way, facilitating their
separation from the urethra.

Extensive Subcutaneous Laceration of the Abdominal Mus-
cles. — -D. N. Eisendrath reports the case of a man of fifty
years who, while intoxicated, was caught between two
street cars pa.ssing in opposite directions. He was
admitted to hospital and presented a swelling about
the size of an orange at the middle of the right iliac crest
and extending somewhat below it. From the fact that
this tumor was distincth' tympanitic on percussion
and could be made to disappear into the abdominal
cavity with a gurgle, he made the diagnosis of a trau-
matic hernia throtigh the triangle of Petit. There
were several other minor injuries. Operation was done six-
teen hours after admission to hospital. Incision over
the site of the iliac swelling showed that only the skin
separated the peritoneal cavity from the external world.
All of the muscles attached to the crest of the ilium
(external and internal oblique, and transversalis muscles),
as well as the transversalis fascia and peritoneum, were
torn loose from their attachments. The skin incision
was enlarged in both anterior and posterior directions,
and the flaps retracted. It was then found that the
injury was far more extensive than at first supposed.
From the quadratus lumborum posteriorly to the middle
of Poupart's ligament in front every structure which
is normally attached to the crest of the ilium and outer
half of Poupart's had been torn from its attachments.
The lower edges of the muscles were irregularly torn and
contused. The general peritoneal cavity had already
been partly walled off by adhesions between the as-
cending colon (which had been displaced inward) and
the anterior abdominal wall. In the iliac fossa were
many loose pieces of omentum. The ascending colon
was contused and dilated. By means of fourteen kan-
garoo tendon sutures the muscles were drawn down
to the gluteal fascia and the defect closed. From the
anterior superior spine of the iliuin to the middle of
Poupart's ligament, mattress sutures of kangaroo ten-
don were passed in a similar manner through the muscles
en masse, and these then anchored by passing the two
ends of the suture through Poupart's ligament itself,
similar to the formation of the posterior wall of the
inguinal canal in the Bassini operation. Small gauze
drains were inserted at each end of the long skin incision.
These were remo\-ed after forty-eight hours. Primary
union occurred and the patient made a slow, though
complete recovery.

July 9, 1904]

MEDICAL RECORD.

La'^ Separation de l'Urine des Deux Reins. Par

Georges Luvs. Assistant du Service des Voies Uri-

naires a I'Hopital Lariboisiere. Preface par Henri

Hartmann, Professor Agrege a la Faculte, Chirurgien

de I'Hopital Lariboisiere, Paris: Masson et Cie., 1904.

Renal surgery is a subject to which a vast amount of study

is being devoted at the present day and, apart from the

surgical treatment of Bright 's disease, no branch of this

department is of greater interest than that of diagnosis

by examination of the urine obtained from each kidney

separately. Among the methods of obtaining the urine

of one kidney immi.xed with that secreted by the other,

that of Luys stands out most prominently.

In the present work the author, after showing the ne-
cessity of this means of diagnosis, reviews and explains
the different methods (ureteral catheterism, compression
of the ureter, and intravesical separation) .jand then treats
of his own device, dwelling on the history of its invention,
its construction, method of employment, action, and
indications. Excellent results are shown in the re-
ports of personal cases, 210 in number, in which the
separator has been used on patients of both sexes and
all ages, and with every imaginable disease of the kid-
neys. Many of these reports are illustrated with well-
executed pictures of the kidneys removed after diagnosis
by Luys' method. The author has not been precipitate
in the recording of his cases, but has waited three years
and has demonstrated the value of his invention over
two hundred times — an experience which gives him the
right to speak with authority.

The book is a timely one, and will be consulted with
profit by all who are interested in renal pathology.
Theorie vnd Praxis der Augenglaser. Von Dr. E H.
Oppenheimer, Augenarzt in Berlin. Mit 181 Textab-
bildungen. Berlin: August Hirschwald, 1904.
The volume is one of 200 pages, and isprincipallj- devoted
to the description of the various kinds of eye-glasses and
spectacles and the theory and art of their construction.
In the first chapter a short history of eye-glasses dating
back to iSoo B. C. is found. The volume of production of
spectacle lenses at the present time is mentioned. The
second chapter describes the manufacture of the ordinary
forms of eye-glasses ; the third, spectacles. Chapter X is
devoted to a description of the proper way of adjusting
glasses to the face. Chapter XI describes in detail the
various kinds of glass employed in the manufacture of eye-
glasses. Chapter XIII treats of the various ways of
numbering glasses.

The book is well illustrated. It is calctilated to acquaint
ophthalmologists with what is being done in the art of
making eye-glasses, and this purpose it accomplishes in a
very excellent manner.

A System of Practical Surgery. By Drs. v. Berg-
MANN, Berlin, v. Bruns, Tubingen, and v. Mikulicz,
Breslau. Edited by Wm. T. Bull, M.D. Vol. II,
Surgery of the^Neck, Thorax, and Spinal Column. New
York and Philadelphia: Lea Brothers & Co, 1904.
The second volume of this work closely follows the ap-
pearance of the first, and the remaining three volumes of
the series are scheduled to come out in rapid succession.
It includes the surgery of the neck, thorax, and spinal
cord, and in the list of contributors are the names of v.
Angerer, v. Bruns, Erhard, v. Eiselberg, Henle, Hof-
meister, Jordan, Kummell, and Riedinger. Their names
are not in all cases, however, appended to the chapters
in the book for which they are responsible, in some
respects an unfortunate omission. The following topics
are considered: Malformations, injuries, and diseases of
the neck, the larynx and trachea, thyroid gland, thorax
and its contents, the mammary gland, the spinal cord,
and the vertebral column. In the latter chapter the sub-
ject of tuberculous spinal ostitis is considered, as regards
diagnosis and treatment, quite as fully as in some special
textbooks on the subject. In this, as well as in other
parts, one is impressed by the evident desire to make the
work practical; more space being given to diagnosis and
treatment than to etiology or pathology, except w-hen
one has a bearing, on the other. The typographical work
is up to the high standard to be found in most American
medical books, and the illustrations are ntimerous.
An Introduction" to Vertebrate Embryology, based
on the study of the frog and the chick. By Albert
MooRE Reese, Ph.D. (Johns Hopkins), Associate
Professor of Histology in Syracuse University and
Lecturer on Histology and Embrj'ology in the College
of Medicine. New York: G. P. Putnam's Sons, 1904.
This volume contains 291 pages and 84 illustrations.
It is, the author tells us, the result of a need for a text-
book on the embrj'ology of the chick and frog, at once
concise and convenient. The volume is intended as an

outline from which the instructor can expand as he see*
fit. The needs of the medical student have been largely
considered, and very little space has been devoted to
theoretical discussions. The treatment of the subject is
convenient for the student, the development being de-
scribed day by day (for the chick, for example, daily up to
the sixth day), instead of organ by organ. The text is
clear and easily followed, and devoid of unnecessary
technicality ; and the illustrations are well selected.
All in all, this little volume forms a convenient manual
for the student.

The Therapeutics of Mineral Springs and Climates.
By I. Burney Yeo, M.D., F.R.C.P., Emeritus Pro-
fessor of Medicine in King's College, London, etc.
Chicago; W. T. Keener & Co., 1904.
Dr. Yeo has become well-known to the profession on
this side of the Atlantic through his excellent "Manual of
Medical Treatment," and his attractive monograph on
"Food in Health and Disease." The present volume
may also be classed as a useful work of reference. Part

I (456 pages), comprising about two-thirds of the book,
treats of mineral springs and contains chapters on the
nature and composition of mineral waters, their action
and modes of application, with the various accessory
methods employed in the internal and external use of
waters, together with a description of the principal Euro-
pean springs, arranged in alphabetical order. As no
geographical limitation is expressed in the title, it would
not have been out of order, nor would it have been prej-
udicial to the practical value of the work, to have in-
cluded some of the American springs, many of which will
take rank with the best of those found in Europe. Part

II relates to the subject of climate, and contains an ac-
count of the several varieties of chmates with a brief de-
scription of the various British and Continental winter and
summer resorts, the therapeutics of sea voyages, the
uses of sanatoria, etc. In this part of the book the atithor
far transcends the geographical limits allotted to mineral
springs and takes his readers as far afield as South Africa
and the Pacific Coast of the United States. It is grati-
fying to obser\-e that while Dr. Yeo is an ardent
advocate of the modem sanatorium treatment of tuber-
culosis, he is by no means to be classed with the latter-day
group of extremists who taboo the subject of climate as
being quite negUgible in the management of this disease.
We think no one can read the excellent chapter on climatic
therapeutics without being impressed by the forceful logic
of the author's views.

The Complete Medic.\l Pocket-Formulary and Physi-
cian's Vade-Mecum. Containing upward of 2,500
prescriptions, collected from the practice of physicians
and surgeons of experience, American and foreign,
arranged for ready reference under an alphabetical list
of diseases. Also a special list of new Drugs, with their
Dosage, Solubilities, and Therapeutical AppUcations,
together with a table of Formula; for Suppositories ; a
table of Formula? for Hypodermic Medication; a list of
drugs for Inhalation; a table of Poisons, with their
Antidotes; a Posological table, a Hst of Incompatibles ;
a table of Metric Equivalents; a brief account of Ex-
ternal Antipyretics, Disinfectants, Medical Thermome-
try, the Urinary Tests ; and much other useful informa-
tion. Collated for the use of Practitioners by J. C.
Wilson, M.D., Physician to the German Hospital,
Philadelphia, etc. Third Revised Edition, Philadelphia:
J. B. Lippincott Co., 1904.
Being alphabetically arranged, this presents a handy
reference book. There are nearh' 2,600 formute. Why
they should be numbered does not appear. The "list of
authorities " seems superfluous. — The lists of new remedies,
poisons, measures, etc., are good.

Immune Sera: H.-emolysins, Cytotoxins, and Precipi-
tins. By Prof. A. Wassermann, M.D., University of
Berlin. Authorized Translation by Charles Bolduan,
M.D. New York: John Wiley & Sons; London: Chap-
man & Hall, Limited, 1904.
The subject of serum diagnosis and therapy, already
grown to considerable proportions, is constantly increasing
in importance. The lack in our language of any simple
and concise exposition of the subject has led Dr. Bolduan,
as he tells us in his preface, to make this excellent treatise
of Prof. A. Wassermann more readily accessible to the
English-reading medical public. For this the thanks of
many are due him, for the subject is presented by the
author in a way which leaves little to be desired by the
seeker after information who has not the time or the oppor-
tunity to study at first hand and in large treatises the
details of this difficult science. Any one, by one or two
careful readings of this little book of 76 pages, can famil-
iarize himself with the whole theory of immunity, as it is
at present held, and so be in a position to understand
much in modern medical literature that else must be to
him a sealed book.

MEDICAL RECORD.

[July 9. 1904

AMERICAN SURGICAL ASSOCIATIOX.
Twenty-Fifth Annual Meeting, Held in St. Louis, June

14, 15, 16, and 17, 1904.
The association met in the Assembly Hall of the Board
of Education, under the Presidency of Dr. N. P. Dand-
ridge of Cincinnati, Ohio.

President's Address. — Dr. X. P. Daxdridge depiarted
somewhat from the practice of his predecessors, and
instead of bringing before the association some medical
topic based on his own work, or attempting a discussion
of some subject of active interest, he took the members
to the back woods, and interested them in the life and
exploits of a pioneer doctor. He depicted a man of
high scientific attainments and true culture, with all the
elements of character which become the doctor and the
man. He gave an exhaustive sketch of Antoine Francois
Saugrain de Vigni, who was bom in Paris, February 17,
1763. He came from a long line of librarians, booksellers,
and printers, who, as far back as Charles IX in Lyons,
and Henry of Xavarre, had served the Royal family in
France. His knowledge of mineralogy made his advice
often called for in the development of the mines in the
Ohio Valley. In the wilderness he supplied himself
with ink from a natural Chalybeate water and an infusion
of white oak bark, and when in need of a fire, lighted
it from a lens made by two water crystals with clear
water between. Dr. Saugrain gave notice of the first
vaccine matter brought to St. Louis, and indigent persons
were vaccinated gratuitously. He practised in St. Louis
till his death, in 1820. He must have been eminently
successful, for he left a large landed estate for the support
of his wife and six children. His scientific work lives
in tradition, and has gained for him the title of the
"First Scientist of the Mississippi Valley."

What Are the Minimum Requirements for Aseptic Sur-
gical Operations in Hospitals Where the Surgeon Is Assisted
by a Large Staff of Internes and by Nurses from a Training
School? — This subject was discussed with great detail by
Dr Geo. H. Mo.vks of Boston, Mass.

Minimum Requirements for Aseptic Operations in a
Hospital in Which the Personnel of the Operating-room
Is Permanent. — Dr A J. Ochsner of Chicago, in a paper
on this subject, pointed out the fact that with a per-
manent personnel a definite system could be developed,
which was most satisfactory, because the observations
which suggested changes as well as those which con-
firmed satisfactorj' methods could be carried through
a large continuous series of cases under unchanged ex-
ternal conditions. Stress was laid upon the importance
of simplicit5' in the methods chosen The less that was
done in any given case, the slighter was the likelihood
of doing harmful things. There should be uniformity
in carrying out a plan of work in order that everyone
connected with the system might know what had been
done and what was to be done by the other members
of the personnel in any given case. Above all things,
the methods should be reasonable in their details. This
would make the work more attractive, and consequently
more satisfactory to those engaged in its prosecution.
The author then gave a detailed account of the system
followed by him and his assistants at the Augustana
Hospital, where he had had an opportunity to develop
uniform methods with permanent conditions during a
period of fifteen years. The sj'stem comprised disinfec-
tion of patient, operator, assistants' and nurses' hands,
instruments, silk, silkworm gut, horsehair, drainage
tubes, hand brushes, dressings, implements, towels,
sheets, etc. Stress was laid particularly upon the danger
arising from tying sutures too tightly, thus causing press-
ure necrosis, which favored the development of micro-
organisms accidentally introduced. The method of
selecting assistants and nurses was described, and a table
llustrating the manner in which each assistant recorded

the progress of the wounds under his care was appended.
Dr. Ch.^rles H.\rrington of Boston, Mass., read a
paper, by invitation, in which he detailed his studies in
asepsis.

Dr. De Forest Will.\rd of Philadelphia said that
surgeons who had to deal with the practical side of asepsis
in surgical operations knew that their results satisfied
them to a certain degree, but it must be confessed that
they had failures, and it was very essential to know
whether the failures were due to the method or methods
employed, or whether there were difficulties which could
not be overcome. Difficulties would beset surgeons, but
the question resolved itself largeh' into one of extreme
care on the part of everyone, from the surgeon down to
the lowest assistant, who had the materials in charge or
in preparation. There could be no doubt that a hospital
which had permanent assistants, permanent nurses, was
the one that was likely to secure the best results from
operative procedures on the patients under its care.

Dr. Chari,es B. Xaxcrede of Ann Arbor, Mich.,
emphasized the two important points, one of which was
inhibition, and the other, tissue resistance. A germ
might be inhibited to the point that would render it safe
in a given wound.

Dr. John E. Owe.vs of Chicago stated that different
results were reported by different surgeons after using
the same methods, and he had often wondered whether
some of them might not have been due largely to the habits
of surgeons. So far as the disinfection of hands was
concerned, a few years ago he was compelled to stop the
use of corrosive sublimate on account of the condition
of his hands, and since then he had been scrubbing them
thoroughly with soap and water, keeping the nails of the
fingers pared down, and afterward washing the hands
with salt solution and alcohol, and he thought his results
were as good in hospital work as where other chemicals
for sterilization were used.

Dr. W. W. Keen of Philadelphia spoke of his own
method and the results which he had obtained by some
experiments. He had adopted for several years past
for the cleansing of his hands, a method which was first
directed to the attention of the profession by Weir, namely,
the use of chloride of lime and carbonate of soda. The
hands were washed thoroughly with soap and water, and
in order to do this he had in his own private hospital and
at the clinic at Jefferson, little egg boilers, which were
practically hour-glasses or sand-glasses that were re-
versible. These were marked "soft-boiled, well done,
and hard Ixiiled. " Soft boiled corresponded to about
three minutes; well done, five minutes, and hard boiled,
seven minutes. He told his assistants that when they
had scrubbed their hands until the sand had reached
"well done, " good and faithful servant, they should stop.
Every person, who took an active part in his clinic, had
a culture taken from under the thumb, or one or two
finger nails, particularly at the root of the nail, and from
the free surface of the skin. During the last winter there
were 213 cultures made, from the hands of himself and
his assistants in the clinic at Jefferson. Of this number
there were only three cases in which any culture was
obtained. This made practically a sterility of 9 per
cent., and an infection of about 3 per cent. There was
but one person who was free at every clinic, and that
was the head nurse, who was a permanent official in the
operating room. All the other nurses, and' all the assistants,
except this principal assistant, changed even,- three
months. He thought the method of keeping such a
record of every person's hands ser\-ed an admirable
purpose by creating a sort of ri\aln.- among those who
were endeavoring to have clean hands before operation,
and it was more to prophylaxis in preventing infection
than in the results obtained, he attributed the value of
the method.

Dr. W. B. CoLEY of Xew York did not believe suf-
ficient stress had been laid upon sterilization of the skin.

July 9, 1904]

MEDICAL RECORD.

and although some authorities maintained it could be
done properly in a few moments before operation, his
experiments showed that with careful preparation the
day before operation, in addition to what was done on the
day of operation, sterilization of the skin even then could
not be said to be perfect. In 250 cases in which he had
examined portions of the skin or Reverdin grafts, taken
from the field of operation immediately before, 25, or
9 per cent. of the cases, showed all kinds of cultures, some
of them being staphylococcus and streptococcus. The
only case of suppuration in two hundred cases showed
a pure culture of the streptococcus. Carefully sterilizing
the hands, using tincture of green soap, applied carefully,
brushing and hot water, then washing thoroughly with
95 per cent alcohol, with the use of rubber gloves, would
give as good results as any of the measures which render
the hands \ery hard. With reference to primarj' union,
an important element in aseptic surgery was to guard
against the bruising of tissues.

A Clinical Review of Forty-Bix Operative Cases of
Duodenal Ulcer. — This was the title of a joint paper by
Dr. Christopher Graham and Dr. Wm. J. Mayo of
Rochester, Minn. The authors stated that a careful
history was of prime importance. The leading symp-
toms in the forty-six cases reported were, first, pain,
which might be due to peritonitis, distention from gas
formation, pyloric spasm, and the irritation of acid gastric
contents on open ulcer. The pain might come on in
colics or last for some hours. Second, vomiting, prin-
cipally of sour, bitter liquids, or if obstruction supervened
of food after varying intervals. Third, gastric insuf-
ficiency from interference with drainage. There was
usually hyperacidity of gastric contents, constipation,
and a great desire for food, although the patient reduced
the diet, and ate often a small quantity, but might fail
to get the relief sometimes obtained in gastric ulcer proper.
In latent cases, evidences of blood in the fecal movements
might be the only sign. Differential diagnosis from
pyloric ulcer in some cases might be impossible. A con-
siderable number of cases closely resembled gallstone
disease, and differentiation often could not be made.
Such an error in diagnosis did not militate against the
clinician, as both conditions were purely surgical and
the differentiation in many cases must be made on the
operating table. During the past eighteen months,
27 per cent, of their operative gastric and duodenal ulcers
involved the duodenum in combination — 753.33 per cent.
There were ^^ males, and 13 females; in 43 out of 46
cases the ulcer was easily detected upon abdominal
exploration as a thick, white, scar-like area. Liability
of duodenal ulcer to perforate was greater than gastric,
but more often safely protected by adhesions. Relatively,
sterile contents was also favorable. In all cases the ulcer
was situated in the first two and one-half inches below
the pylorus, and entirely above the entrance of the com-
mon duct of liver and pancreas, with its alkaline secre-
tion, showing the effect of the gastric juices on the
duodenal wall. In all doubtful cases of differentiation,
between duodenal ulcer, pyloric ulcer, and gallstones,
the authors recommended making an incision through
the right rectus muscle, one inch to the right of the median
line. Gastroenterostomy best met the indications, in
that it diverted the gastric contents. In acute perfora-
tion, suture was recommended, with suprapubic drainage,
with after-treatment, and exaggerated Fowler's position,
sitting posture. The 46 cases were divided into five
groups: (i) Acute perforation of chronic ulcer, 4 cases,
2 deaths. (2) Acute hemorrhage in chronic ulcer, i
case, one death. (3) Duodenal ulcer with gastric com-
plications, 25 cases, one death. (4) Duodenal ulcer,
with gall-bladder and liver complications, usually due
to adhesions from chronic peritonitis, 9 cases, one re-
operation, no deaths. (5) Eight cases, chronic pain and
distress with debility, no deaths. Total, 47 operations.
46 cases. Five operations for acute conditions, with

three deaths; 42 operations for chronic conditions, with
one death.

Dr. E. WvLLYs A.n-drews of Chicago had seen in the
last year or two several cases in which a marked hyper-
plasia, patches of exudate, with thickening of the wall of
the duodenum, ulceration of the first inch and a half of
the duodenum connected with a similar condition of the
pylorus, had produced such a degree of massive thickening
that clinically, at the time of operation, it was indis-
tinguishable from carcinoma. In one such case the
operation, which was a McGraw elastic ligature gastro-
enterostomy, left him in a dissatisfied state of mind, as he
feared he shotild have done a more radical extirpation,
and yet, in this particular case, it was his fortune to do a
second operation for obstruction a year after the first
operation, and he found, very much to his surprise, abso-
lute disappearance of the thickened massive wall, which
had formed in the first place and simulated carcinoma.
This was what Mayo himself called attention to, namely,
when the obstruction was relieved, when the flow was
permitted from some other point, the inflammation, or
ulceration, at any rate, the hyperplasia disappeared at
the point of irritation, and secondary to this again, when
obstruction had been relieved by drainage below, the
drainage below ceased to act, and again the opening be-
came closed, so that the surgeon had to do sometimes a
secondary gastroenterostomy.

Dr. Joh.n- B. Murphy of Chicago said the practical les-
son the paper taught was the frequency of occurrence of
duodenal ulcer; that it was not recognized, and that it
was not differentiated from gastric ulcer or gall-bladder
disease, whether it was of infective or of stone origin.

Dr. Alexander Hugh Ferguson of Chicago asked Dr.
Mayo if he had outlined for himself the class of cases in
which he would do a posterior gastroenterostomy: also
the class of cases in which he would do gastrojejunostomy
or Finney's operation. The speaker mentioned one case
in which he did a pylorectomy, removing the end of the
pylorus, and a portion of the duodenum, with an excellent
result.

Dr. Mayo, in closing the discussion, and m replying to
the remarks of Dr. Ferguson, said he did not know that
they had ever tried to excise any of these ulcers excepting
in connection with Finney's operation. They were irreg-
ular and thick; they led to large vessels, close to the
common duct, and it was difficult to get a good stump.
He thought the best thing to do was to make a gastro-
enterostomy, which would afford, at least, temporary
relief, but the gastroenterostomy opening was very likely
to contract, so that food would after a time continue to
pass down over the duodenal ulcerated surface, and some-
times these patients would return for a second operation.

Complete Removal of the Shaft of the Tibia, with
Restoration of the Bone. — Dr. George Ben Johnson- of
Richmond, Va., detailed seven cases of this operation.

Dr. De Forest Willard said it was greatly to be
regretted that not only the family physician, but many
surgeons, treated such cases as Dr. Johnston had reported
for rheumatism, when there was really no sign of that
disease, and they were, from the beginning, cases of acute
suppurative osteomyelitis. Then came the septic symp-
toms. The physician treated them for typhoid fever and
other conditions, until they drifted into the hands of sur-
geons, with bones absolutely destroyed, the majority of
them crippled for life, with deformity of the legs. These
cases from their incipiency were virulent in type, and the
only time for treatment was forty-eight hours after the
onset, and the quicker the surgeon got inside the bone,
the better. If cases of appendicitis demanded early op-
eration, surely it was doubly important that cases of
acute osteomyelitis should be diagnosed and operated
early.

Dr. A. J. Ochsn'Er stated that in a large porportion of
cases in which the shaft of the bone was entirelv loose.

MEDICAL RECORD.

[July 9. 1904

when the periosteum was incised, if the bone was left in
place, there would be a regenaration of a considerable
portion of the apparently dead bone. If one took such
cases as had been described, made an incision which
extended from one end of the bone to the other, split the
entire periosteum, made it necessar>' for the flow of lymph
to be away from the tissues, left bone there as a bone
graft, he had found in a considerable number of cases
that there would be a regeneration of a large portion of
this bone.

Dr. John Collins Warren of Boston said the subject
was one that should be thoroughly discussed, and a
message given to the profession to realize the importance
of this septic process, so that cases of acute osteomyelitis
might be sent to surgeons early and treated properly. As
to treatment, the great point was to prevent the spread of
sepsis. This might be accomplished by trephining the
bone, by proper disinfection, by a comparatively moderate
operation, or, it might be necessary in certain cases to do
quite a radical operation.

Dr. P. S. Conner of Cincinnati, Ohio, said that in some
of these cases the disease originated superficially. The
cases were uniformly mistaken for erysipelas. The red-
ness of the overlying skin was taken as an indication of
the existence of the disease. Then, we had a condition
simulating typhoid fever after the disease had existed for
a considerable length of time, or rheumatism for a while,
then typhoid fever, when the condition did not subside.
Early boring of the lower end of the tibia would put a
stop to the trouble. A moderate incision would not in-
frequently end the trouble if boring did not.

Dr. S. H. Weeks of Portland, Me., said that while many
of these cases began as a periostitis, requiring a simple
incision down upon the bone, there were many others
which commenced as an acute osteomyelitis in the medul-
lary canal, and he believed under such circumstances when
an incision was made down to the bone, there should be
an opening made into the medullary canal, and that canal
drained.

Unavoidable Post-operative Calamities in Abdominal
Surgery. — Dr.'M.\URicE H. Rich.\ri)Sos' of Boston read a
paper with this title, which was based upon his experience
more especially in abdominal surgery, and related exclu-
sively to fatal cases. Four classes of calamities were con-
sidered: (i) Suppression of urine; (2) inexplicable deaths,
with symptoms of local and general sepsis, but without
any detectable bacterial source; (3) uncontrollable
capillary hemorrhage; (4) p\dmonary embolism. Sup-
pression of urine could be regarded as an unavoidable
accident only when it took place after the urine had been
shown to be normal by the most searching study. The
influence of ether alone in causing suppression after
operations was not regarded as sufficient and sole cause
of this calamity. It was doubtless true that failure
of the kidneys properly to perform their functions was due
to some pathological change in the secreting substance,
if not a pathological change, a tendency to glomerular
irritation or real inflammation, but a change or tendency
which could not be detected beforehand. Such suppres-
sion of urine, however, might be prevented by the avoid-
ance of all but imperative operations whenever there was
the least evidence of renal disease, especially an insuf-
ficiency in the elimination of urea. Renal suppression
was not believed by the writer to be the result of ether-
ization alone. In certain very rare instances death had
taken place after abdominal operations without any
pathological cause whatever. In one illustrative case,
after an aseptic, though difficult and bloody operation,
the patient presented the typical clinical picture of fatal
general peritonitis. The pathologist at the Massachusetts
General Hospital could find no evidence whatever of bac-
terial infection at the autopsy or in the laboratory. That
there was an infection the essayist had no doubt, but by
a germ which produced none of the usual physical signs
of sepsis, which failed to grow on ordinary media, and

which was not stained by the ordinary media. Un-
controllable capillary oozing might be regarded as un-
avoidable, and beyond power of prediction only when it
took place after careful examination of the blood with
reference to its coagulability, and other possible evidences
of a tendency to bleed. Capillary hemorrhage from
jaundice might be in certain instances uncontrollable. It
could be regarded as uncontrollable only when operation
must be performed in spite of the evidence of the tendency
to hemorrhage. The coagulation tumor did not reason-
ably assure safety against bleeding, even if it was shown
experimentally to be brief. The author's last fatal
hemorrhage in jaundice took place from the capillaries of
the lesser cur\'ature of the stomach, remote from the
operation area, though the blood coagulation tumor was
perfectly satisfactory. In another case a fatal and uncon-
trollable capillary ooze followed an operation upon the
common duct after a year of biliary fistula. In this case
no bile had entered the intestine during the existence of
the biliary fistula. The most frequent of such rare
calamities was sudden death from pulmonary embolism.
The cause of death could be neither predicted nor pre-
vented. It occurred with no peritonitis. The probability
of embolism being the result of a phlebitis was considered.
In the author's experience, in a considerable number of
deaths there were no premonitorj' symptoms whatever,
while in cases of phlebitis, definite and unmistakable, no
such accident occurred. Pulmonary embolism had been
observed most frequently after pelvic operations upon
women with large uterine or ovarian tumors, and espe-
cially in women lone exsanguinated by fibroids.

Papillary Cysts and Papillary Tumors of the Ovaries.
— Dr. S.'^MUEL Pozzi of Paris, France, read a paper
on this subject, in which he summarized as follows: (i)
Papillary tumors of the ovary, cystic or solid, must not
be considered as always malignant. Some of these tumors
never undergo malignant degeneration, and do not relapse
after removal. Some relapse after a long time, and
locally without metastases. (2) A careful distinction
must be made between carcinomatous generalization,
which takes place through the lymphatics and blood-vessels,
and simple grafts which result from contact, or from the
growing over the peritoneum of detached papillary vegeta-
tions of the o\-ary. This process is benign and can be
compared to the grafting of papillomas and warts of the
skin. (3) Some of the tumors undergo a malignant de-
generation which is for some time limited, but may later
extend all over the mass, and which at last brings on
a real generalization with cancer metastases. Before
this last period, and at the outset of the malignant trans-
formation, it is quite impossible to discern it with the
naked eye, and microscopical investigations are needed.
The prognosis is always uncertain in operations of this
kind before a thorough pathological examination. Even
such examination may lead to misinterpretation, if it
has not been carried all over the tumor, for the degenera-
tion may be limited to a small part of the growth. (4)
When positive symptoms of malignancy are absent,
such as cancerous cachexia or visceral metastases, opera-
tors must always treat these tumors as if they were benign,
and proceed to remove, to the largest extent possible, the
neoplasm. The disseminated growths, or even small
parts of the papillary tumor detached and lost in the
peritoneal cavity may disappear. In other cases they
may be the origin of local recurrence. But these re-
lapses can be treated successfully by secondary opera-
tions. (5) Frequency of successive invasion of both
ovaries by papillary tumors, furnishes an indication to
remove the adncxa on both sides, even if one is still
healthy, at least in women who are near the change of
life. In young women it would be better to preserve
a non-diseased ovary. (6) In bilateral papillary tumors
the operative technique can be greatly improved by
performing partial or total hysterectomy, according to
the case. (7) Drainage is not necessary when the cysts

July 9, 1904]

MEDICAL RECORD.

ha\-e no outside vegetations, and when there is no ascites.
But in case ascites exists for some time, it would be well
to drain the peritoneal ca\4ty. Incomplete removal,
or even an exploratory section, in unoperable cases, is
often accompanied by a real diminution of ascites, with
local and general improvement. "

Ankylosis Treated by Arthroplasty. — Dr. John B.
MuRPHV of Chicago spoke on this subject. He men-
tioned three types of ankj-losis, namely, ankylosis from
periarthritis; ankylosis from capsular lesions, and bony
ankylosis. Bony ankylosis could be reUeved. Tissue
could be interposed to prevent reestablishment of bony
union, and with the recognition of the changes which
occurred in fat close to the aponeurosis, a joint could be
produced with a serous-secreting surface. His experi-
mental work had shown that after the remo\-al of the
hip-joint in a dog, cartilage, s^-no^•ial membrane, and
the articular surfaces in their entirety, with replacement
of tissue in the acetabulum, and replacement of bone
again, he had produced a typical sii'no\-ial membrane
in the sense of a hygroma. In the production of hygroma
pressure on fatty tissue had a tendency to bring about
a coalescence of the small fatty capsules. The shaft
of these capsules produced a serous secretion, and there
was developed a condition which was seen in housemaid's
knee, over the trochanter of the boilermaker, and over
the wrist of the stonecutter. A serous-secreting sur-
face was brought about. This coxild be done in a joint.
The surgeon could restore joints to practically their
normal condition. The first case he reported was one
of bullet wound of the abdomen. The bullet passed
through the abdomen a Uttle to the right of the median
line, passed across the abdomen, perforated the intestine
eight times, fractured the head of the femur, lodged in a
pocket, remained there, worked its way out through
ulceration, and was finally voided through the intestine.
The wounds in the intestine were sewed up, and the patient
recovered, with a sinus. The speaker saw the patient
with ankylosis of the leg at right angles. He passed
around a skiagraph which showed bony union. After
removing the head of the femur transperitoneally, curet-
ting and remo\'ing the bony debris from the ilium, the
wound was allowed to heal, and a plan was devised for
the restoration of the joint and the relief of deformity.
He decided that it was necessary, first, to expose the
joint and to secure bony tissue for the new head. Second,
it was necessary to interpose between the fragments not
only muscle, but fascia, covered with fatty tissue, be-
cause the fatty tissue here, subject to pressure, like the
fascia lata of the trochanter, formed hygromata. A
U-shaped flap was made, carrying w^ith it fascia lata
and all the superficial tissue and skin, then the joint
sawed from around the trochanter major. None of the
muscles was divided. A circular chisel was used to
chisel out the bone in all directions, and with the assis-
tance and leverage of the femur and chisel a fracture
was produced at the base of the cavity, and the head,
which was new bone formation, as the original head was
removed, was thrown out in connection with the neck,
rounded off -nith bone-cutting forceps, and curette used
to enlarge the cavity. The next step of the operation
was to separate the fascia lata with its fat and a few
fibers of the gluteus muscle; a flap was swting in behind
the muscular attachments, and the trochanter major put
in around the head of the femiir and sewed to the nesk.
The neck was made short to prevent reunion of the
fibrous portion of the capsule which remained, because
if the capsule remained in its fixed position, the ankylosis
would continue, and this was one of the practical points
he derived from this particular case. The trochanter
major was sutured to the neck, the head replaced, the
trochanter major roiuided off, the flap turned down and
the wound drained. The result of the operation was
ideal. Dr. Murphj' passed around a photograph showing
the patient as he stood ia the erect position, and the

degree of fle.xion obtained at the end of four months
after operation. The patient now had perfect motion and
flexion. He mentioned other cases on which he had
operated by this method, with gratifying results. The
method was largely intended for the treatment of joints
^vith ankylosis.

Ifew Aids in Diagnosis of Surgical Diseases of the Kidney.

— Dr. A. T. C.^BOT of Boston read a paper on this sub-
ject. His conclusion from the experience he had had and
from his study of the work of others, were that ^segregation
of the tuines was of great use sometimes in deciding the
question as to which kidney was diseased, or even as to
which was most affected. Determination of the functional
capacity of the kidney by testing the elimination through
it might be of assistance by adding strength to what evi-
dence we had, but would be often misleading if too im-
plicith' relied upon for deciding operative measiu-es.

Report of a Case of Acute Pancreatitis Associated with
Gallstones. — Dr. J.\mes Bell of Montreal said that the
demonstrated facts in his case were: (i) That in March,
1898. there were all the characteristic lesions, as well
as the signs and symptoms of acute pancreatitis, and at
the same time an apparently quite healthy liver and gall
passage, -with two or three stones in the gall-bladder.
(2) That all signs and symptoms of pancreatitis dis-
appeared, the patient recovering, and considering himself
quite well until nearly two years later, when a new train of
symptoms developed, which were characteristically those
produced by gallstones. (3) Three years after the attack
of acute pancreatitis it was demonstrated that while
extensive and serious pathological changes had taken
place in the gall-bladder and bile ducts, all local signs of
acute pancreatitis had during the same period of time
entirely disappeared (subperitoneal fat necrosis, and
swelling of the pancreas) ; that was to say, that acute
pancreatitis developed before there were any pathological
changes in the gall-bladder and bile ducts, and that while
such changes were taking place the pancreatitis was
recovered from. These facts would seem to be at variance
with modem views of the etiology of acute pancreatitis,
which tended to attribute this condition in a general way
to a pathological change in the common bile duct due
to the passage of gallstones from the gall-bladder to the
intestine.

The Treatment of Congenital Cleft Palate : A Plea for
Operations in Early Infancy. — Dr. Trvm.^.n- W. Brophv of

Chicago read a paper, by invitation, on this subject.
After referring to the work of Lamonier, Kirmisson, Roux.
and many others in this field, the essayist stated that
after having studied carefully the literature and the
methods pursued by other operators, he had endeavored
to overcome the objections and to avoid the difficulties
with which the older surgeons contended, and he was
satisfied that the most desirable time to select for operating
was within three months after birth. In operating at
that time one was able to secure more satisfactory results
than later in life, and avoided the objections usually
raised by surgical wrisers. He believed in operating at
as early an age as practicable after birth, preferably
within three months, and his experience of twenty years
in operations performed for the closure of cleft palate,
at from ten days to fifty years of age, including 927 opera-
tions, had more and more justified the practice. Among
the advantages mentioned in favor of early operations,
were the following: Surgical shock was less because the
nervous system of a young child was not well developed,
and it was not, therefore, capable of receiving the same
impressions that it would later in life. Furthermore,
young children usually reacted better. All mental appre-
hensions were eliminated, and alarm and dread were among
the most powerful factors in producing shock. FoUo^^ing
early operations there was much less deformity, for all the
tissues, bony as well as soft, developed naturally and
according to accepted types. When the operation was

MEDICAL RECORD.

[July 9, 1904

postponed for a few years, it was very difficult to secure
as good results. When the operation was made in early
infancy, the parts were sufficiently developed to give
possibility for normal speech when the child had reached
a speaking age. The author described his method of
operating on cleft palate in detail, a description of which
has heretofore been published in both dental and medical
journals. In conclusion, the author stated that if opera-
tions were made later in life, the patient should be placed
under the instruction of one \\-ho had the perseverance,
the ability, and the patience to teach him how to over-
come the defective speech whifh he had acquired.

The Evolution of Surgery. — Dr. J. Ewing Mears of
Philadelphia read a scholarly paper with this title. He
divided this unfolding of surgery into three periods of
time: (i) That which extended from the beginning to the
time of Ambroise Par^, 1517-1519; (2) the use by Johns
Collins Warren (1846) of ether as an anasthetic in surgical
operations, and (3) the disco^'ery and introduction into
general use by Sir Joseph Lister (1860-1875) of the anti-
septic treatment of wounds. Each period was taken up
and considered in a masterly manner.

A Mechanical Device for Gastric and Intestinal Anasto-
mosis. — Dr. P. B. H.\RRi.VGTON- of Boston described a ring
for the purpose of intestinal anastomosis. The advan-
tages of this ring were stated as follows: (i) Safety and
speed. A complete resection and suture can be easily
done in fifteen minutes, and with as great speed as by any
more protracted method. (2) Cleanliness. Assisted by
clamps, the purse-string sutures prevent even a mucous
ooze, while the continuous stitch is being placed. (3)
The intestinal suture is more easily done over the ring
than without it. (4) It is safe to use a single laj-er of
continuous stitches, since the ring allows a perfect approx-
imation to be made, and afterward protects the suture
until adhesions have formed. (5) The handle is very
useful for holding the intestines in convenient positions
for sutures. (6) It is not necessary to sew up any of the
layers, since a study of specimens from animals and human
beings shows that the mucous membrane will slough in
any case, and that repair is more rapid when the mucous
membrane is not sutured. (7) The presence of the ring
guarantees a free opening at the site of operation. (8)
In case the continuous stitch should be improperly applied,
the weak spots are protected by the ring itself for at
least three days, until the ring breaks down. This allows
strong adhesions to form. (9) After operation the ring
holds the suture immovable, and acts like a splint. The
weights of the individual segments of the ring vary, as
most other appliances of a similar nature.

Dr. J. W. Dr.^per Mairy of New York City, by invita-
tion, stated that instead of using the elastic ligatiu-e at the
Laboratory of Columbia University, they had been em-
ploying twine. The specimen which he exhibited was
made with the elastic ligature put in by a square knot,
thus differing from Dr. McGraw's technique; but for the
last three months he had obtained as good results by using
simple twine instead of the elastic ligature. The method
of introducing the twine might follow the McGraw tech-
nique, although the triangular stitch possessed a very
distinct advantage over it. This stitch punched out as
much tissue as might have been included in the triangle.
As to time, it would cvit through in less than three and a
half days. It must be very tightly tied. This was the
sole requirement to success. Dr. Maury demonstrated on
a chart the technique of introducing the triangular stitch,
and stated that he included about one-third the circum-
ference of the gut in the stitch. The gastric triangle
should, as a rule, be made larger than the intestinal. He
then passed around photographs of specimens made by
this method, and a preparation from the gut of a pig.
which demonstrated how free an anastomosis might be
established. He also showed a number of circular bits of
twine, which had been used in executing the technique.

They had cut the triangle out and had been recovered
after their passage through the rectum.

The Subtle Force of Radium. — Dr. Robert .\bbe of
New York City narrated his experience with this new-
therapeutic agent, saying that radium had a powerful and
seemingly beneficial effect upon cases of recmrent car-
cinoma. Cases were cited in point. He mentioned one
case of virxUent, typical carcinoma of the scirrhous type, in
which the carcinomatous nodules were reduced to one-
third their original size by radiomization. The agent had
been used in cases of lupus, superficial epitheliomata.
carcinoma, rodent ulcer, superficial sarcomas, etc. In
cases of superficial recurrent carcinoma of the breast, if
radium was applied to the diseased area for a considerable
time, sav an hour, then the patient permitted to go. and
the agent reapplied at intervals of two or three days, the
carcinomatous masses would melt away in some cases.
In other instances, these masses would disappear under
the use of the «-ray, still others wotUd resist the action of
the a:-ray, while radium would act beneficially. Radium
had an extraordinary power in inhibiting the growth of
mslignant cells in some cases.

Dr. W. W. Keen of Philadelphia said that one positive
fact was worth a dozen negative ones. One could not get
away from the facts presented by Dr. Abb^ and others in
regard to the use of radium. On the other hand, members
of the profession ought to report their negative as well as
positive results. He had had an experience now covering
twentv-two cases in which radium was used. Whether
his results were due to the quality of radium, to a differ-
ence in the character of the growths, to the method of
using it, or what not, he did not know. But to sum up
his experience, in not one single case had there been the
slightest benefit, except in one feature, and that was as to
pain. Unquestionably in cases of carcinoma, patients had
suffered less and in a large number pain had disappeared.
In one case of tic douloureux of the lower jaw the man
left the hospital at the end of a month practicalh- well.
In the course of six or eight weeks the patient wrote him
that he had had a recurrence of the pain. Dr. Keen
wrote him to return for treatment, but had heard nothing
from him since, and whether the pain had disappeared or
not, he did not know. He had used the German instead
of the French radium. Some of his specimens had varied
from 17.000 radio-activity up to a larger radio-activity,
until finally he was able to obtain one specimen with
1,800,000 radio-activity. He regretted to say that his
experience had not been satisfactory with the use of
radium.

Gastrostomy in CEsophageal Stricture. — Dr. James H.
Dunn of Minneapolis, Minn., said that cicatricial stricture
was the most serious benign affection of the oesophagus.
Retrograde and through and through treatment of certain
cesophageal strictures had been recognized since the
operation of Loretta, in 1883; but discoveries and im-
provements in operative technique had finally completely
changed the situation, leaving surgeons in a position to
approach one of these cases with a very safe and certain
technique, and to fill the following indications: (i) A
gastric fistula which would not leak, and close spontane-
ously. (2) To get a reliable guide through the canal with
perfect safety and certainty. (3) To divide the scar
tissue sufficiently. (4) Relative asepsis and rest of the
wounded surface, prevention of stagnation of food, and
for' a time the irritation of its passage. The value of the
Stamm-Keder form of gastrostomy was generally under-
stood, but it was only when one fully appreciated by
experience that any cesophageal stricture might be com-
manded perfectly and with precision by means now at
hand, through very small gastric fistula;, even the size of
a No. 20 French catheter or less, that all the advantages
of the method appeared. The steps of the operation were
described. A modification of Dunham's wire and spindle
bougies was suggested as somewhat simpler and more

July 9, 1904]

MEDICAL RECORD.

handy. The writer had not found it necessary to use
guards to prevent the epiglottis and stomach fistula from
chafing. By this plan but one anaesthesia was necessary
in each case. The fistulse had not leaked and had promptly
healed spontaneously. A caliber admitting of free swal-
lowing was reached in from one to three weeks, and an
appro.ximately normal caliber achieved in from two to
four months, after which the tendency to relax had been
imperceptible. The author reported three very severe
cases, one in a girl, aged nineteen, following typhoid
ulceration, and two in children, aged nine and two years,
from the ingestion of concentrated lye. Repeated at-
tempts had failed to reach the stomach through the mouth
in all these cases.

The Bridging of Nerve Defects. — Dr. Chas. A. Powers
of Denver, Col., said the difficulties in the way of prepar-
ing a satisfactory paper on this subject were due to the
indefinite manner in which nerve suture was treated in
medical literature, to the widely scattered and badly
indexed material collected and published by Chipault, to
the fact that much of the material in the literature of the
subject described operations upon animals, that a large
proportion of operative cases in men were reported before
the establishment of a permanent result, and to the fact
that in case of failure, it was not easy to say that a given
bad result was due to a faulty technique in the operation
itself, as a similar result might have followed direct suture
of the fragments. The author reported in detail a per-
sonal case of transplantation of four inches of the great
sciatic of a dog to the external popliteal of a man. Union
was prompt. The fragments stayed in place, and the
immediate result seemed to be encouraging, but the
ultimate result was a total failure. Examination and
report were made eight years after operation. Cases of
the bridging of nerve defects gathered from literature
showed the following number : Grafting, 2 2 ; flap opera-
tions, 11; implantations (anastomosis), 10; resection of
bone, 7; suture i distance, 3; tubulization, i. Analysis
of these cases showed that grafting was a failure and
should be discarded, while the results in flap operations
and anastomosis were about the same, something over
50 per cent, of the cases being successful. While these
last operations were not very promising, they seemed at
present to be the methods of choice.

Final Results in Secondary Suture of Nerves. — Dr.
Emmet Rixford of San Francisco, Cal , reported three
cases of secondary nerve suture, of the ulnar at the wrist,
of the musculospiral and the facial at the stylomastoid
foramen, six, four, and two years respectively after opera-
tion. In the first case the atrophic thenar, hypothenar,
and interosseous muscles regained their normal volume
and function, save in so far as motion of the fingers was
limited by adhesions, the result of fixation and chronic
arthritis. In the second case the musculospiral nerve
was sutured eight weeks after rupture, complicating a
fracture of the hiunerus. A defect of three centimeters
was overcome by shortening the hiunerus that amount
and the result after four years was complete motor and
sensory restoration of function, with slight atrophy,
one-half centimeter difference in circumference in the
forearms. In the third case the facial nerve was severed
by a narrow tooth beneath the mastoid process. Com-
plete facial paralysis. Suture at eight weeks after the
injury. In order to secure tissue for the sutures, the
mastoid process was cut away with the surgical engine,
and the external wall of the fallopian canal removed for
five or six millimeters. Result after two years: Face
symmetrical, when in repose; eye closes in sleep; may
be closed at will; angle of mouth, tip of nose and chin
can be drawn to the paralyzed side. The prognosis
in secondary suture was but little, if at all, inferior to the
prognosis in primary suture. In the presence of infection,
secondary suture was preferable to primary. All scar
tissue should be removed, including the whole of terminal
neuroma of central segment, the nerve ends united by

absorbable suture with the least possible" traumatism.
Defects, if not too great, could be overcome by stretching
which should be done before section of the ner\'e ends or
by shortening of the bone in certain cases.

Primary Carcinoma of the Liver. — Dr. Leonard Free-
man of Denver, Col., reported a case of primary car-
cinoma of the liver on which he had operated, with
freedom from recurrence at the end of sixteen months.
After dealing with the different methods of operating,
he reported his case in detail.

Thyroidectomy for Exophthalmic Goiter. — Dr. Chas.
H. Mayo of Rochester, Minn., in a paper with this title,
said the subject of goiter was still imsettled, both as
regards etiology and treatment, although hundreds of
articles had been written upon it. Recent investiga-
tions concerning the lymphatic system and ductless
glands rendered the subject very interesting at this time.
E.xophthalmic goiter was a distinct type, with many
symptoms, involving the mental, muscular, digestive, and
circulatory fimctions, the most common being the tachy-
cardia without other cause. While the mortality was
comparatively high, it was among those cases which had
already run the gauntlet of most known remedies for the
disease, and should not be entirely laid at the sur-
geon's door. The surgical methods were exothyropexy
ligation of the thyroid arteries, removal of the cervical
sympathetic ganglia, thyroidectomy, and the physio-
logical effect of operations upon other regions. The
author and his brother had operated upon 130 goiters;
40 were of the exophthalmic type, and of these, 6 died,
as the restilt of the operation. In the first 15, there were
four deaths due to lack of judgment in accepting almost
moribimd cases. There were but two deaths in the last
2 5 cases. Very severe cases were subjected to ^-ray ex-
posures, and with belladonna given internally for a few
days or weeks previous to operation. Their own cases
showed marked improvement in all who survived the
operation. Of these 50 per cent, made a very early
recoverj', especially of the severe symptoms, such as
tachycardia, nervousness, and tremor; 25 per cent, did
so after several months, and 25 per cent, were improved,
yet suffered from irregular recurrence of some of the
major symptoms.

Gallstones in the Common Bile Duct. — Dr. S. H. Weeks
of Portland, Me., read a paper on this subject, in which
he considered the diagnosis and prognosis, and said that
impaction of a gallstone in the common duct rarely
caused marked distention of the gall-bladder; it caused
dilatation of the branches of the hepatic duct, and might
resxilt in pronounced and even fatal jaundice. Obstruc-
tion of the common duct was always accompanied by
jaundice. The jaundice was intermittent or remittent
where the calculus floated in an enlargement of the com-
mon duct, because the system would eliminate the color-
ing matter of the bile in the inter\-aL The cystic duct
might be occluded, and give rise to grave sj-mptoms,
without there being any trace of jaundice or any history
of biliary colic. Jaundice with distended gall-bladder
not due to gallstones was presumptive evidence of malig-
nant disease. Jaundice without distended gall-bladder
favored the diagnosis of cholelithiasis. The treatment
was necessarily surgical.

Dr. A. P. Jones of Omaha, Neb., read a paper on
"Primary Splenomegaly, Accessory Spleens, Splenec-
tomy, " and reported an interesting case.

Dr. S. J. MiXTER of Boston, reported a case in which
he removed the upper jaw for extensive osteosarcoma,
with an excellent result, considering the formidability of
the operation.

Dr. Rudolph Matas of New Orleans, La., exhibited
and described a new interdental splint which he had
recently devised for the treatment of fractures of the
jaw, particularly the lower jaw, without bandages.

Dr. Alexander Hugh Ferguson of Chicago exhibited
a patient upon whom he had performed renal decap-

MEDICAL RECORD.

[July g, 1904

sulation for chronic interstitial nephritis three and a
half months ago, with an excellent result.

Officers. — The following officers were elected: Presi-
dent, Dr. Geo. Ben. Johnston of Richmond, Va. ; Vice-
Presidents, Dr. Emmet Rixford of San Francisco, Cal.,
and Dr. James Bell of Montreal ; Secretary, Dr. Dudley P.
Allen of Cleveland, Ohio; Treasurer, Dr. Geo. R. Fowler of
Brooklyn, N. Y.; Recorder, Dr. Richard H. Harte of
Philadelphia; Counselor, Dr. N. P. Dandridge of Cincin-
nati, Ohio.

San Francisco, Cal., was selected as the place for hold-
ing the -next meeting, the date to be decided by the
officers and committee of arrangements.

NEW YORK ACADEMY OF MEDICINE.

SECTION ON OBSTETRICS .\ND GYNECOLOGY.

Stated Meeting, Held April 28, 1904.
Dr. A. Palmer Dudley, Chairman.
Occiput Posterior Positions of the Vertex. — Dr. John O.
PoLAK of Brooklyn read this paper. (See page 55_)

Occiput Posterior Positions. — Dr. S. Marx read this
paper. (See page 54.)

Dr. Malcolm McLean continued the discussion and
said that a great deal had been written on this subject, but
unfortunately there seemed to be an extension of words
without conveying much clear and definite teaching, but
the paper of Dr. Polak was the best he had ever heard on
the subject of occiput posterior positions.

In occiput posterior positions one of the greatest dangers
encountered was from the injudicious interference with
forceps. The majority of these cases, if left alone, he said
would rotate to the front and become practically normal ;
but, unfortunately, such labors are very tedious, slow, and
uncertain. He had never yet seen a normally acting
uterus in occiput posterior positions; therefore, it had
been suggested that some malposition of the foetus causes
it to act in an irritable way, with short pains, etc., and the
short, inefficient pains, or contractions, kept up an unusual
number of hours which was so trying to the patient, to
both her mental and physical condition, to the family and
to the attending phycisian. Such an existing condition
often drove the physician to performing operations in an
improper manner and at an improper time. This was his
experience in the average run of these cases in the average
physicians' hands. The consequence was that when the
occiput was at the right sacroiliac synchondrosis, the
forceps would be placed to the sides of the child's head
before a correct diagnosis had been made. This he had
seen done time and again, and the result invariably
was that as soon as the forceps was applied wth the view
of bringing what was supposed to be the high occiput on
the left, down and spirally to the front, an obstruction
impossible to pass was made mechanically. The result
was that the women were very much inj\u-ed by the
operation, and it was only after the forceps had slipped
after many wretched and repeated attempts had been
made, that it became apparent that a correct diagnosis
of the position had better be made. Then it was to late
to do much. The position should have been discovered
at the earliest moment and then the methods tried that
were advocated by Dr. Polak.

Dr. McLean said that one of the greatest difficulties
encountered in occipxit posterior positions was the rotation
of the body of the child in order to secure proper anterior
position of the occiput. After getting the occiput in the
anterior plane it should be kept there; it was easy to get
it to the front but very difficult to keep it there. In many
of the cases of occiput posterior positions, manual inter-
ference was required, because the head was in such a rela-
tion to the peh-is that it tended to maintain its posterior
position; it was not the result of improper flexion only,
but there was a positive tendency of the occiput to remain
in the posterior position. He had again and again seen
attempts made by different methods to bring the occiput

to the right anterior plane, holding the occiput there until
a pain brought it down, then forceps applied and there
resulted the same old story, the occiput was on the pos-
terior of convex side of the forceps. Now, why? In a
great many cases the body of the child influences the head,
and, in many cases, this influence was produced by the
cord being passed around the shoulder and neck of the
infant. Therefore, when attempts are directed to bring
the shoulders around they will not come beyond a certain
point, they will just describe a certain part of the arc of a
circle and no more. Continual attempts to produce this
mechanical rotation produces torsion of the spine of the
child, because of the fixation of the body. The moment
that difficulty of this kind is encountered he caused the
occiput to rotate all the way around to the left anterior
and this with perfect ease. He had gone to see cases pre-
pared to do podalic version and had found the cord, in
some cases, was only six inches in length from the placenta
to the shoulders of the child. The cord was shortened
by the position of the child, and in such cases he said it
was much easier to take the long circuit and bring the
occiput to the left anterior plane rather than to the right;
thus bringing the body of the child right around and
unwinding the involved cord which had acted as a check
to rotation in the opposite direction to the right.

Dr. Egbert H. Grandin said that about ten years ago,
at a meeting of the American Gynecological Society, held
in Brooklyn, he read a paper before an audience com-
posed of men from all over the United States and dealt
with the same topic, occiput posterior positions. At that
time he had charge of two maternity services, and it had
then been his experience to see sixteen cases of occiput
posterior positions within six weeks. He made that
statement and surprise was expressed at the frequency of
the position. He said he was glad to know that the
prevalence of this position was now clearly recognized.
To his mind it was the most common position which
called for interference in the ordinary type of obstetrics.
Nowadaj-s he did not do much obstetrics, but in 95 per
cent, of the cases in which he was called in consultation he
felt pretty sure that he was being called to see cases of
occiput posterior positions, as a rule in the cavity or
impacted at the outlet. The conclusion which he reached
ten or twelve years ago had suffered but very little modifi-
cation as the result of a greater experience. As a rule,
occiput posterior positions occurred because there was
some disproportion between the presenting part and the
pelvis, either the pelvis being too small or the fetal head
too large.

Dr. Grandin said that he failed to see how the "new
school" could recognize an occiput posterior at the brim
or in the cavity, because this school tried to tell us not to
make internal examinations but to rely entirely upon
external manipulations for diagnosis. He did not think
the average man could recognize such malpositions by
external examination. With the occiput posterior and at
the brim, with the membranes unruptured, with the cervix
dilated or dilatable, it was his custom to do a podalic
version followed by quick extraction of the child. In that
class of cases ■n-ith membranes ruptured and the head
descended posteriorly into the cavity, he asked what
should be the rule of procedure? It was in this class of
cases that the reader of the paper used axis traction.
Dr. Grandin said that if it was simply a question of merely
rotating the head he would agree with the method ad-
vocated but it was not simply a question of rotating the
head. The head could be rotated through a certain
circuit without damaging the fcetus, but one could not
rotate it a great ways without killing the child because
the trunk of the child would not follow the head in its
rotation. Therefore, he thought the method advocated
was not rational. The object should not be rotation of
the head but rotation of the body of the child and here
was where the point raised by Dr. McLean entered in;
rotate both head and body and while the patient was under

July 9, 1904]

MEDICAL RECORD.

deep surgical anaesthesia; the entire hand in the vagina
should grasp, not the head, but the shoulders of the child
and rotate the foetus in the direction it went the most
easily. If one tried to rotate it to the left and found it
would not go it meant that the cord was interfering and
then rotation should be made in the other direction. If
the head was found at the outlet and impacted he said
there was but one thing to do in the interest of the mother,
operate upon the child. Of late years he said he had
learned more about this class. Dr. Isaac Taylor, two or
three months before his death, asked Dr. Grandin to
select from his stock of instraments what he desired and
then, after his death, to give the balance to the Maternity
Hospital. Dr. Grandin selected a short-handled forceps,
which he carried nowadays with his action traction forceps
and angiotribe. If the head was impacted at the outlet,
with a living child, he applied these short-handled forceps
in the inverted sense and so secured flexion; flexion once
secured one could then deliver the child. Get flexion and
deliver, although with loss of integrity of the pelvic floor.
Dr. Grandin said that ten years ago he was severely
criticised when he advocated manual manipulation at the
brim; now he advocated version.

Dr. Joseph Brown Cooke agreed with all that Dr.
Grandin had said and believed that occipitoposterior
positions were much more common than generally sup-
posed. It was an easy presentation to diagnose by
abdominal palpation. In his experience he had found the
postural method to be of but little value because the
rotation of the head was almost always to the front in
spite of it. He believed it to be inexcusable for anyone to
attempt to apply the forceps without a definite knowledge
of the presentation. Before the application of the forceps
there should be a dilated or a dilatable cervix and the
patient should be completely under the influence of the
anaesthetic.

Dr. Robert A. Murray referred to an unusual number
of cases of occipitoposterior presentations that had
occurred at the Maternity Hospital between the years
1890 and 1893, and he thought this was due to the fact that
there were so many women of foreign birth and with
deformed pelves. Whenever such a position occurred he
said that it was necessary to determine why. It was, as a
rule, not due to the size of the child but to some malforma-
tion of the pelvis. One should know exactly just what the
size of the child's head was and its relation to the pel»is,
and if this could not be done readily then the patient
should be placed under complete anesthesia and the
hand introduced into the pelvis for a more thorough ex-
amination. The mortality in these cases he considered to
be very great, and was apt to be complicated with em-
barrassing circumstances, such as lacerations, eclampsia,
prolonged labors, bleeding, etc. He believed that many
of these cases should be treated by version. In most of
the textbooks it was stated that, in the mechanism of
occipitoposterior positions, the head instead of extending
was forced down to the floor of the pelvis and gets imder
the spine of the ischium and then commences to rotate,
i.e. cannot rotate until it gets beneath that spine. Dr.
Murray said that it could if one endeavored to correct this
extension by efforts at flexion, pushing up the frontal
portion and so allow the forehead to come do-nm. He said
that out of one hundred cases of occipitoposterior posi-
tions four or five w-ould rotate into the hollow of the
sacrum. In these cases it was very difficult to apply the
forceps; to apply them transversely was almost an im-
possibility. One could not pull the head straight down
because of the great damage done; the child might be
killed and the mother greatly injured.

During the years 1890 and 1893 there were 957 cases;
among these there were 119 low forceps operations and 12
high forceps. In 9 labor was induced, in 4 there was
eclampsia, in 6 hemorrhage, in 28 version, in i caesarean
section was performed, in i laparotomy, in 7 craniotomy,
and in 7 episiotomy. Among these cases there were 4

deaths, 3 from eclampsia, and i from ruptured uterus.
There were no deaths due to the use of forceps or ta
version.

Dr. A. Palmer Dudley said that his experience in these
cases had been purely surgical. He said he had never
done a craniotomy and had had one case of ruptured
uterus.

Dr. S. Marx said he was not so much afraid of occipito-
posterior positions as he once was. The early operative
treatment of these cases he believed to be a mistake.
When there was occasion to operate one should operate
quickly and before the membranes ruptured if possible.
He did not know how many of occipitoposterior presen-
tation he had seen but in not one of them had the mem-
branes not ruptured early. If the membranes had
ruptured he would hesitate to interfere because in 90 per
cent, of the cases rotation would occur spontaneously
during the course of the labor. Manual rectification had
not been successful with him. If he should find it neces-
sary to go into the uterus and if he was in a position to do
version he said he would do an elective version. If this
was undertaken late in the progress of labor it would be a
difficult thing to do, and then it might be a better pro-
cedure deliberately to perforate the child's head. Dr.
Grandin stated that by rotation with the axis traction
forceps, it would wring the child's neck; he asked if the
same thing would not occur with the hand in the uterus
and attempts made at rotation.

Dr. Robert A. Murray said that when he made the
statement regarding the correction of the position of the
child's head, he meant that the hand should be passed up
to grasp the shoulders and efforts made at rotation of the
shoulders as well as of the head.

Dr. Marx said that he did not believe the question of
contracted pelvis entered at all into the consideration of
this subject any more than the consideration of the con-
dition of the child's head in its relation to the spinal
column. If the child was in the dolichocephalic condition
in position with the spinal column in the middle part of
the base of the skull there wovild be a question whether
the head would extend or take a position of semi-flexion.
The relation of the head to the spinal colume should be
kept in mind. The moment it struck the superior plane
of the pelvis flexion occurred and, in the mechanism,
more had to do with the condition of the child's head.
The question arose as to what constituted a "contracted
pelvis." He did not know unless it meant that the head
was too big for the pelvis.

With regard to making a diagnosis of occipitoposterior
positions by external manipulation alone he agreed with
Dr. Grandin in what he said in reference to the so-called
"new school." This new school made the diagnosis so
easily because in 95 per cent, of all cases the head presents
and, when certain things operated, it was onlj' necessary"
to say "occipitoposterior position" and you would
almost always be correct. He said that he examined as
often as he deemed it necessary and guided the head with
his hand in the vagina around to the anterior.

With regard to the rotary axis traction he said he was
not often compelled to use it. In spite of what Dr.
Grandin said in criticism of it he believed that Dr. Grandin
would use it before he died.

It was rather interesting for him to hear Dr. Murray
speak of the cases occurring in the early go's because those
cases occurred while he was assistant surgeon to the
Maternity Hospital and were his. Dr. Marx's, owti work.
In a great many cases he -believed that perforation should
be the method of election. During every year he had
about one dozen perforations to do in his consultation
practice.

Dr. George Tucker Harrison took issue ■s\dth those
who said the}- should make as many examinations as they
choose. He believed the fewer examinations made the
better, because of the difficulty of getting the hand per-
fectly aseptic. He did not apply forceps to correct

MEDICAL RECORD.

[July 9, 1904

positions of the head; if the head was high he preferred
podalic version. With this method he had satisfactory
results and, therefore, did not care to change.

Dr. John O. Polak closed the discussion and said that
he believed all were in accord with the position assumed
by him, i.e. in cases of head above the brim, treat by
version ; and in those cases with the head engaged in the
cavity or on the floor, treat by forceps. In those cases
of occipitoposterior positions with the membranes un-
ruptured he believed in giving Nature a trial and not
interfering. In a case with membranes ruptured, with
the head at the brim, if the head was engaged in the
pelvis and could be rotated to the front with rotation of
the body, it then was better to deliver by forceps than
to attempt version, if the operation was to be done by
one not an expert. He said this because all were not
experts in the management of the after-coming head and
in extracting the arms.

The position taken by Dr. Marx regarding craniotomy
he said deserved praise and also comment. He had seen
two cases of rupture of the uterus caused by the applica-
tion of the forceps when the head was not engaged, while
at the pelvic brim and in both of these cases the child was
dead. It was to him surprising how many difficulties
could be overcome by intelligent craniotomy, and for
three or four years he had been doing craniotomy when
the mother's life was endangered.

Contagious Diseases— Weekly Statement. — Report of
cases and deaths from contagious diseases reported to
the Sanitary Bureau, Health Department, New York
City, for the week ending July 2, 1904:

Measles

Diphtheria and croup . . .

Scarlet fever

Smallpox

Varicella

Tuberculosis

Typhoid fever . . .

Cerebrospinal meningitis

Case*.

Dcatht.

.369

386

130

. . .

330

'5°

A Strange Result of Iodoform Dressing. — H . McNaughton-
Jones reports this case. The patient, a woman of thirty,
had recently undergone an abdominal operation. The
course was favorable until the third day after the opera-
tion. Irritation and some smarting in the neighborhood
of the wound was then complained of. The wound had
been stitched with celloidin-zwirn, a pad of moist steri-
lized lo-per-cent. iodoform gauze being placed over it
covered with coeletin. On raising the dressing the nurse
found some slight swelling and redness along the area of
the incision. The irritation increased and the next day
the iodoform was removed and the wound lightly sponged
over with some weak formalin solution, dried and dusted
with dermatol, covered with plain sterilized gauze, and
protected with coclitin. The distress continued and the
next day several large vesicles appeared. The arms and
hands now became involved, later the legs. There were
no constitutional symptoms. The skin healed by first
intention. It was learned that many years before
the patient had had 'an ulcer on the leg. This had
been dressed with iodoform \vith much the same
results as in the present instance. From her childhood
the patient had suffered from an eczematous tendency. —
Midical Press and Circular, February 24, i()04.

Report of a Case of Perforation in Typhoid Fever in a
Child of Six Years. — John H. Topson describes this case.
The child was a male Hebrew child who had been healthy up
to the time of this present illness. For two weeks he
had been suffering from malaise, fever, cough, and head-
ache. Diarrhoea and abdominal v'^i" developed, which
seemed to be located in the right iliac region. The day

before his admission to the hospital he began to vomit.
E.xamination showed his lungs to be clear. The ab-
dorain was distended and tender, particularly in the
right iliac region. There were a few suspicious spots.
Projectile vomiting developed. When seen by the writer,
the temperature was 98.8° F., pulse 120, respiration 48
There were noted, abdominal distention, generalized
rigidity, tenderness, especially in the right iliac region,
abscence of liver dulness, thoracic type of respiration, and
abscence of peristaltic sounds. The general condition
was fair, considering the advanced local symptoms. A
diagnosis of intestinal perforation during typhoid fever
was made. Operation showed the perforation to be in
the ileum, about eight inches from the colon, about the
diameter of an ordinary lead pencil. The after-history
was like that of many cases of operation in the presence of
general peritonitis. Improvement followed for twelve
hours, but at the end of the first day vomiting and other
signs of peritonitis occurred, the pulse weakened, and at
the end of seventy-two hours the patient died. The per-
foration probably occurred at least twenty-four hours
before operation. After death the perforation was found
to be firmly occluded and water-tight. Perforation is
rarely encountered at such an early age as in this child.
The writer believes that the case of this patient is possibly
the youngest yet reported. — Archives of Pediatrics.

Health Report. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the Surgeon-General, U. S. Marine Hospital Service,
during the week ended July 2, 1904.

SMALLPOX — UNITED STATES.

CASES. DEATHS.

California, San Francisco Tune 12-10

District of Columbia, Washington .June 11-18 4

Florida, at larKC June 18-25 7 i

GeorKia. Macon June 18-25 i

Illinois. Chicacio June iS-25 i

Danville June 18-25 i

Louisiana. New Orleans June 18-25 53 imported

Mar\land. Baltimore June 18-25 2

Massachusetts. Lawrence June 18-25 1

Michigan. Detroit June 18-25 3

Missouri, St. Louis June 18-25

Nebraska, Omaha June 18-25 2

South Omaha June 18-25 •• i imported

New Flampshire, Manchester June iS-25

New Jersey. Jersey City June 12-19

New York, Buffalo June iS-25.

New York June 18-25.

Niagara Falls June 18-25.

Ohio, Toledo June 18-25.

Pennsylvania. Altoona June 1 8-25 .

Johnstown June 18-25.

Philadelphia June r8-2s.

Pittsburgh June iS-25.

Tennessee, Memphis June 18-25.

WashimTton. Tacoma June 13-20 i

Wisconsin, Milwaukee June 18-25 6

S.MALLPOX — POREIGM.

BcUtium. Bnisscls June 4-1 1

China. Hoiy^komi May 14-28 s

France, Marseille May 1-31

Paris June 4-11 10

Great Britain. Glasgow June 10-17 20

Leeds June 11-18 3

London June 4-11 ai

New-Castlc-on-Tync June 4-1 1 8

Nottingham June 4-1 1 3

Sheffield May 28- June 11... 3

India, Bombay May 24-3 1

Italy, Palermo June 4-11 i

lava. Batavia May 7-14 8

Mexico, Mexico lune s-12 5

Russia, Moscow May 28- June 4. . . . 11

. . . . 2, 1 imported
from Baltimore.

2 imported,

1 imported.

I 3 cases in

suburban districts.

7 I

Odessa June 8-16.

.M:

St. Petersburg May 28- June 14. . .

Warsaw May 21-iS

Spain, Cadiz May 1-31

Turkey, Constantinople June s-12

YELLOW PBVBR.

Mexico, Tampico June 1 1-18.

Vera Cruz June 26.

imported

Hawaii. Honolulu.

fniin Progreso.

PLAGUE — INSULAR.

June 21 I

PLAGUE — FOREIGN.

China, Amov May 31 Increasing.

489

100

Hongkong May 14-28. . . .

596

Formosa May 14-28. .

India, Bombay May 14-31

Calcutta May 21-28

Karachi May 22-29

CHOLERA.

Ohina. Hongkong May 14-28 13

India. Calcutta -May ^1-28

Medical Record

A JFeei'/y Jour/ia/ of Medicine and Surgery

Vol. 66, No. 3.
Whole No. 1758.

New York. July i6, 1904.

$5.00 Per Annum.
Single Copies, JOc-

OMgtnal ArtirlrH.

PYELITIS COMPLICATING PREGNANCY.*.

Bv EDWIN B. CRAGIN. M.D.. •

NEW YORK.

The occurrence during pregnancy of a marked rise of
temperature with pain and tenderness on the right
side of the abdtimen is always a source of anxiety
to the obstetrician, and its diagnosis and prognosis
are matters which deeply concern him.

Although several able articles, by Vinay,' Reed,'
Brigand.' Haberlin,' and others, have appeared
describing the condition, it is not generally recog-
nized by either specialist, or .general practitioner,
that pyelitis is a not infrequent cause of the above
■symptoms.

The condition was first accurately described by
Reblaud at the surgical congress in 1892. That it is
not rare in occurrence is evidenced by the fact that
during the past winter the writer has met with five
•cases in private consultation work, and including these
lias seen ten since September, 1900.

The etiology of the condition seems to depend,
according to Vinay, upon two factors: (i) Com-
pression of the ureter by the pregnant uterus. (2)
Infection of the urinary tract above the point of
■compression.

I. Compression of the Ureter by the Pregnant
Uterus. — Experiments upon animals have shown that
the urine is excreted under low pressure. Ludwig
•demonstrated that the pressure in the renal pelvis
■normally does not exceed 10 mm. of mercury. It
requires, therefore, but little compression of the
ureter to retard the current.

That compression of the ureter with resulting
■dilatation does occur in pregnancy is proven by the
records of autopsies on pregnant women by Stad-
feld, Olshausen. Loehlein, and others. Stadfeld in
16 autopsies on pregnant wonien, found 9 dilated
•ureters. In all the writer's cases and in all the
.authentic cases of pyelitis in pregnancy which he
could find reported the lesion was primarily right-
sided and usually confined to the right side. Many
explanations of this have been given. According
to Olshavisen,' the right ureter is the one most often
compressed and dilated in pregnancy. In 16 cases of
•dilated ureter found by him in autopsies on pregnant
women, 12 were unilateral, and of these 12, lo were
right-sided and two were left. As causes of the
greater compression of the right as compared with
the left ureter the following have been suggested:

1. The greater prominence, at the brim of the
■pelvis, of the right over the left common iliac artery
•exposes the right ureter to greater pressure between
the uterus and the iliac artery of that side.

2. The rotation of the uterus on its long axis from
left to right, forward, places the uterus and its con-
tents more in the right oblique diameter of the
pelvis than in the left, and thus exerts more pressure
"Upon the right ureter than upon the left.

3. The greater frequency of the fetal head in the

♦Read at a meeting of the American Gynecological
Society in Boston, May 24, 1904.

right oblique diameter of the pelvis increases the
frequency of pressure upon the right ureter.

In support of this view may be mentioned the fact
that in 8 of the writer's cases the po-sition of the
fetal head was noted, and in these 8 cases, the head
occupied the right oblique diameter in 7 ; there
being 6 in the L. O. A. position, and one in the
R. O. P.

Theoretically one would expect, from the greater
tone of the abdominal and uterine walls, more com-
pression, and hence more cases of pyelitis, in primi-
gravidte than in multigravida?, and that was borne
out in my cases, there being 7 primigravidas and 3
nudtigravidiE. This is contrary to the experience of
Vinay, amon,g whose cases there were only 2
lirimigraviihe and 7 nuiltigr;ivid.e.

2. Infection of the Urinary Tract above the Point
of Compression. — From the frequent appearance of
tln' bacillus typhosus in the urine of typhoid-fever
patients and from experiments on animals, it would
seem that in many infective processes the organisms
may be eliminated by the urine without appreciable
injury to the urinary tract, provided this tract is in
no way obstructed. On the other hand, the experi-
ments of Reblaud and lk)nneau on animals show that
after an aseptic ligature of the ureter, the injection into
a distant part of the body of either streptococci or
colon bacilli can produce a pyonephrosis, it being a
descending infection.

Hence with a ureter compressed by the pregnant
uterus, the infection of it and the renal pelvis is
favored. The infecting organism in the pyelitis of
pregnancy is usually the colon bacillus. This was
the organism found in three of my cases, the only
ones in which the urine was examined bacteriologi-
cally, and has been found to be the infecting organism
in all reported cases examined bacteriologically v/ith
two exceptions — one by Vinay, in which the strep-
tococcus was found, and one by Lop which showed
the gonococcus.

The period of pregnancy at which the pyelitis is
most likely to occur is between five and eight
m<jnths. In all but one of my 10 cases the attack
appeared at that time. In 3 it occurred at five
months; in 2 at six months; m 3 at seven montns;
in one at eight months, and in one at term.

During the last two years I have also met with
three cases of pyelitis developing during the puerper-
ium. These were probably of the same origin as
those occurring during pregnancy, and recovered
under the same treatment, but as no bacteriological
examination of the urine was made, and as ascending
infection could not be positiveh' excluded, they are
not included in the present discussion.

The general course of pyelitis in pregnancy maybe
seen from the following brief abstracts of cases
which have come under my observation:

C.\SE I. — Mrs.F. G.,aged twenty-five, IV gravida.
Admitted to the Sloane Maternity Hospital, Septem-
ber 13, 1900. For five weeks previous to admission
she had suffered with frequent and painful micturi-
tion, and for the last three weeks with pain in the
right lumbar region, increased by coughing or other

MEDICAL RECORD.

[July 1 6, 1904

motion. For the week previous to admission there
had been a rigor each morning, followed by fever,
sweating, and headache. On the day following ad-
mission, her temperature was ioi.6° and there was
tenderness over the right kidney. Her urine was
acid and contained many pus and epithelial cells.
She was delivered of a full-term child September 15,
two days after admission. Position of child L. O. A.
On the day following delivery the afternoon temper-
ature was 103.8°. She was given a urinary anti-
septic, and on the fifth day the temperature came to
normal and remained so thereafter. The urine
gradually became clear. Her highest temperature
while in the hospital was 103.8°. It remained above
100° for four days.

C.\SE II. — Mrs. L., aged twenty-three, primi-
gravida. Admitted to the Sloane Maternity Hospi-
tal, August 31, 1 90 1. She was in the seventh month
of pregnancy, anaemic, and complained of pain over
the right side of her abdomen. Her urine showed
pus cells and a trace of albumin. Her temperature
on admission was 102.8'. She was given a urinary
antiseptic, fluid, diet, and large draughts of water.
Her temperature and tenderness over the right
kidney subsided in lour days and the urine gradually
cleared. Her highest temperature was 102.8". It
remained above 100° four days. She was normally
delivered November 11, 1901, and made a good
convalescence. The position of the child was
L. O. A.

Case III. — Mrs. M. G., aged twenty-three, III-
gravida. Admitted to the Sloane Maternity Hos-
pital, September 19, 1901, complaining of severe
pain in the right lumbar region. Her pregnancy
was seven months advanced, and she stated that she
had had fever in tie afternoon for several days.
Her urine was acid and showed pus and epithelial
cells. There was a trace of albumin^ Her temper-
ature on admission was 102.8°. She was given a
urinary antiseptic, milk diet, and large draughts of
water. Her temperature reached normal on the
eighth da}' and remained so thereafter, the urine
gradually clearing. Her highest temperature while
in the hospital was 104". Her temperature remained
above 100° for seven days. She was normally
delivered two months later. Position of child
L. O. A. Her puerperal temperature did not reach
99°.

Case IV. — Mrs. M. H., aged thirty-seven, XIII-
gravida. Admitted to the Sloane Maternity Hospital,
April fio, 1903, complaining of sharp pain over the
right kidney. Her urine was acid and contained
pus and epithelial cells. Her pregnancy was seven
months advanced. By May 1 2 the pain had ceased and
the urine was nearly clear. At no time during her
stay in the hospital did she show any rise of tem-
perature above 100°. The position of child was
R. O. A.

Case V. — Mrs. D., aged twenty-four, native of
United States, primigravida. Admitted to the
Sloane Maternity Hospital, May 18, 1903, stating
that for two days she had suffered with pain in the
right lumbar region and fever. On admission her
temperature was 102.4°. Her urine was acid and
showed pus and epithelial cells. Her leucocytes
numbered 22,000. She was delivered of a full-term
child on the day following admission. Position of
child R. O. P., rotating to R. O. A. In spite of
urinary antiseptics, ice-bags to the kidney, fluid
diet, and large draughts of water, the patient
gradually grew worse, and on June 3 the right kidney
was removed by Dr. Joseph A. Blake. The kidney
showed several small abscesses in its substance, and
bacteriological examination showed the colon bacillus.
After a tedious convalescence the patient completely

recovered. Her highest temperature previous to the
nephrectomy was 104°. Her temperature prior to
the nephrectomy was above 100° for sixteen days.

Case VI. — Mrs. M. G., primigravida, seen in con-
sultation with Dr. Palmer A. Potter of East Orange,
N. J., October 14, 1903. Her pregnancy was five
months advanced. She had had an irregular fever
for several days with an occasional epistaxis. Her
temperature when I saw her was 104°. For three
days prior to my visit she had complained of pain in
the right lumbar region. The case looked a good
deal like typhoid fever, and that was my first
probable diagnosis. The Widal test, however, was
negative, and subsequent examination of the urine
showed it to be acid with pus cells, renal epithelium,
bacteria, and a trace of albumin. She was given a
urinary antiseptic, fluid diet, and large draughts of
water. On the third day following the commence-
ment of the urinary antiseptic, the temperature came
to normal and remained so thereafter. Her highest
temperature was 104°. Her temperature remained
above 100° for nine days. The urine gradually
cleared. She subsequently went to term and was
delivered of a living child. Puerperium normal.

Case VII. — Mrs. G., aged twenty-six, primi-
gravida, seen in consultation with Dr. George E.
Steel of New York, December 13, 1903. She was
six months pregnant, and for forty-eight hours had
been complaining of pain on the right side of the
abdomen in the region of the vermiform appendix.
Her temperature was 102°, pulse 130. The site of
greatest tenderness was near the McBumey point.
It looked like a case of appendicitis, and that was
my probable diagnosis on my first visit. Examina-
tion of the urine next day, however, showed it to be
acid and to contain pus cells, hyaline casts, and
albumin. Previous to the attack of pain, the urine
had been normal. The diagnosis was changed to
that of pyelitis, and she was given a urinary antiseptic
with fluid diet, large draughts of water, and an ice-
bag over the right kidney. Her pain and tem-
perature subsided in three days and she made a
speedy recovery, although the urine showed pus
cells and casts for more than a month. Her highest
temperature was 102°, highest pulse, 130; the
temperature remained above 100° for four days.
She was delivered at term, March 10, 1904. Position
L.O.A. Puerperium normal.

Case VIII. — Mrs. C, aged twenty-seven, primi-
gravida, seen in consultation with Drs. C. T. Adams
and F. F. Ward of New York, March 4, 1904. She
was five months pregnant, and for the month
previous had complained of pain and tenderness on
the right side of the abdomen, especially in the region
of the right kidney, which could be felt enlarged and
tender. Her temperature during the month prior
to my visit had been a varied one, ranging from
normal to 104° with intermissions of several days
when the temperature was normal. No malarial
organisms were found and the Widal test was nega-
tive. Her urine was acid and contained pus cells, a
trace of albumin, and a few hyaline casts. The
diagnosis of pyelitis was made and she was given
a urinary antiseptic, fluid diet, and large draughts of
water with an ice-bag over the right kidney. Her
temperature and pain subsided in two weeks after
beginning the urotropin, but the urine contained
pus for .1 month longer. Her highest temperature
was 104°, highest pulse 118. Her temperature was
above 100° for sixteen days. She is now progressing
normally in her pregnancy.

Case IX. — Mrs. P., aged twenty-four, primigra-
vida, seen in consultation with Dr. D. E. O'Neil of
New York, April 10, 1904. She was about six
months pregnant and for three weeks had been

July 1 6, 1904]

MEDICAL RECORD.

complaining of pain on the right side of her abdo-
men. She had had several slight rigors. Her mic-
turition had been frequent and painful. On exami-
nation her right kidney was found enlarged and ten-
der. Her urine was acid and contained considera-
ble pus. The filtered specimen showed no albumin.
Cultures from a catheterized specimen showed the
colon bacillus. She was given a urinary antisep-
tic with fluid diet and large draughts of water. Her
temperature and pain subsided in about ten days
after beginning the urinary antiseptic. She is now
progressing normally in her pregnancy, but the urine
still contains a little pus. The position of the child
is L. O. A.

Case X. — Mrs. B., aged twenty-eight, primigrav-
ida, seen in consultation with Dr. Edwin Stern-
berger of New York, April 29, 1904. She was about
five months pregnant, and for two days had been
complaining of pain on the ride side of the abdomen,
especially in the appendicular region and in the
back. This pain at times was intense. Her urine
was acid, contained a trace of albumin, considerable
pus, and the bacteriological examination showed
abundant colon bacilli. Her right kidney could be
palpated, was enlarged and tender. For several
days her pain was much worse every other day.

On May 10 -her leucocytes were 14,400; red cells,
4,120,000; urea, 296 grains. May 16, leucocytes
16,000. From April 27 to May 6, in spite of the
pain in the region of the right kidney and ureter,
the temperature did not rise above 100.4°. On
May 7 the temperature reached 101.2", and on
May 10 104°. For the next three days she be-
came progressively worse, her temperature on the
evening of May 13 reaching 105.6", and it seemed
to me that operative interference would be de-
manded on the following day. The next morning,
however, found the patient better, and under the
advice of Dr. Willy Meyer of New York opera-
tive interference was postponed. The patient
steadil)' improved, the temperature reaching normal
in four days. This case has been characterized by
more pain than any of the others under the observa-
tion of the writer. Opiates in some form have been
frequently required. Her highest temperature was
105.6°. It remained above 100° for seventeen days.
The temperature at the time of writing is normal,
but the pain, although less severe, has not entirely
disappeared. Aside from opiates for the relief of
pain, her chief treatment has been with urinary
antiseptics, fluid diet, and large draughts of water.
From the above cases the symptom-group can
fairly well be pictured:

Pain in the right lumbar region sometimes very
acute, sometimes only elicited by palpation or
motion. The pain often follows the course of the
ureter from kidney to bladder. A rise of tempera-
ture, usually quite high at some time during the
attack, 102° to 105°, although in one of my cases
(Case IV) the temperature did not reach 100°. In
cases with high temperature rigors are not infre-
quent.

Irritability of the bladder with frequent and painful
micturition is common, but the infection is a descend-
ing one, and the cystitis, when it does occur, is usually
secondary to the pyelitis and ureteritis. The right
kidney can usually be made out enlarged and tender.
The urine is acid, at first may contain only a trace of
albumin and perhaps a few casts, to be soon followed
by pus cells, renal c fntheliiitn , and bacteria. The fil-
tered urine often shows no albumin. The pus cells
are usually more abundant as the pain and temper-
ature subside. The urine often contains pus cells
for a month or more after the constitutional symp-
toms have disappeared.

One of the features of chief interest in pyelitis:
complicating pregnancy is the diagnosis. In manjr
cases this is easy if the possibility of the condition'
is borne in mind. Pain and tenderness in the region:
of the kidney, a rise of temperature, and an acid
urine containing pus may point at once to the diag-
nosis of pyelitis. On the other hand, it must be
remembered that when an abdomen is occupied by
a uterus pregnant from five to eight months the pal-
pation of the other abdominal organs is often diflS-
cult. Furthermore, there are other conditions
which may give symptoms resembling it. The
three conditions most likely to be confused with
pyelitis in pregnancy are, judging from the writer's
experience, appendicitis, typhoid fever, and salpin-
gitis.

In some of my cases, especially Cases VII and X,
the point of greatest tenderness has corresponded
closel}^ -R-ith the McBumey point, and appendicitis
has been strongly suggested. In each of these cases
the diagnosis was made from the condition of the
urine. The reason for the point of tenderness cor-
responding with the McBurney point seemed to be
that pressure at this point forced the uterus back
against the ureter and thus increased the pain. The
leucocyte count in these cases of pyelitis resembling
appendicitis has seemed to the writer lower than one
would expect in an appendicitis case correspond-
ingly ill-.

In Case VI the irregular fever and the epistaxis
resembled typhoid fever, and it was only after the
negative Widal test, the explanation of the epistaxis
by the amenorrhoea of pregnancy, and the examina-
tion of the urine that the correct diagnosis was made.
The differential diagnosis between pyelitis and sal-
pingitis can usually be made by the history, the
bimanual examination, and the careful examination
of the urine.

From the above cases it will be seen that the chief
aid to the diagnosis of pyelitis in pregnancy is. the
careful examination of the urine; chemical, micro-
scopical, and bacteriological.

Although the pain may be very severe and the
temperature high, even 104" or 105° for a few days,
the prognosis of pyelitis complicating pregnancy is
usually good. With the exception of Case V, in
which the pyelitis started at term and in which the
substance of the kidney was infected as well as its
pelvis, all the cases of my series recovered under
medical treatment, the temperature and pulse sub-
siding to normal in from four to thirty days; the urin-
ary changes perhaps persisting for a month more.
Judging from my own cases and from the reported
experience of other observers, if the kidneys have
previously been healthy, pyelitis complicating a
pregnancy of from five to eight months advance-
ment, which is the usual period of the complication,
justifies a favorable prognosis of complete recovery
under medical treatment.

In a few cases, however, there are recurrences dur-
ing the pregnancy, and the possibility' of a pyelitis
becoming a pyelonephritis, as occurred in case V,
just referred to, must not be lost sight of. This lat-
ter possibility seems more likely the nearer the com-
plication approaches full term and the puer-
perium.

The medical treatment which the writer has
empiloyed in all the cases under his observation is.
as follows: Rest in bed; fluid diet, especially milk;:
large draughts of water: urinary antiseptics: ice-bag:
over the kidney, and, if this fails to relieve the pain,
an occasional opiate. In many cases, saline cathar-
sis has given marked relief. If, in spite of this treat-
ment, there is evidence of extension of the infection

MEDICAL RECORD.

Quly 16, 1904

to the kidney substance, surgical interference by
nephrotomy or nephrectomy is indicated.

Interruption of the pregnancy is seldom, if ever,
necessary or advisable.

BIBLIOGRAPHY.

1. L'Obstetrique IV, 1899, pp. 230-256.

2. Philadelphia Medical Journal, December 9, 1899.

3. Revue Pratique d'ObsUtrique ct de Pidiatrie, XIV,
1901.

4. Miinchener medizinische Wochensckrift, February 2,
J 904.

5. "Sammlung klinischer Vortrage, " 39, Gynakologie,
Nr. 15, 1892.

10 West Fiftieth Street

THE TRUE EDUCATION OF MIND AND
BODY.*

Bt RICHARD COLE NEWTON. .M.D..

MONTCLAIR. N. J.

To anyone who s-tops to think a moment, it must be
very plain that there is an incalculable waste of
power and energy in human life. Man's spiritual,
mental, and phj'sical powers are capable of almost
infinite development. It is true that we are
hampered by many limitations, the span of our life is
so short, and so much of this brief space must be
given up to learning what has already been done by
others in any ])articular field, not to mention the
entire purview of human knowledge, that there is
only a short time left for original investigation.
Furthermore, only a fairly brilliant mind is capable
of absorbing the existing store of human knowledge
in any one profession or science, and only com-
paratively few men and women have the opportunity,
the industry, and the physical and mental strength
to become really learned. This, however, is b}' no
means equivalent to saying that any man during his
life on earth makes the best practicav use of his time
and opportunities.

Most men are engaged in the sordid pursuit of
money, and spend a great deal of energy and thought
in endeavoring to circumvent their fellows and ac-
cumulate money which may never benefit them.
The struggle for bread is so fierce and our love of ease,
of sensual enjoyment and social distinction is so
pronounced, that nine men out of ten think thej'
have no time for self-improvement, either mental or
physical. This is far from true. Practically any
man or woman might be wiser, happier, and healthier
than he or she now is. There is unfortunately an
inadequate and one-sided notion of education preva-
lent in America. Not only do we ordinarily neglect
the physical side of education, but we are wont to
look upon a college degree as itself an end, and as the
distinguishing mark of an educated man. Whereas
it at best only marks the end of one period of his
development. The only true and satisfying attitude
of the mind toward education is that of the his-
torian, Freeman, who wished it to be said of him
that he died learning. Neither the mind nor the
body can safely be allowed to stagnate. If there is no
progress there will surely be retrogression.

A non-functionating attribute invariably deterior-
ates. This is an immutable law of nature, and is
perhaps in no respect more strikingly manifested
than in the non-developing minds of those who do not
study. A man's conduct may improve and his ex-
perimental knowledge of the world increase with
years, but unless he actually studies and exercises
his mental faculties, his intellectual horizon will not
broaden, nor his mental vigor increase as he grows
older. On the contrary, his prejudices will take
deeper root and the bonds of conventionalism will
bind him more closely. This mental inactivity we
call conservatism ; but it is really a state of mental

*Read before the Morristo-n-n Medical Club.

inertia, in which prejudice, or a blind adherence to
previously formed opinions, takes the place of
thought and independent judgment.

Of course the majority of non-thinkers have never
exercised their minds enough to have learned to
think clearly and logically. Stevenson said that he
"had only to read books to think, but the mass of
people are only speaking in their sleep." How often
do we see professional men, teachers and others,
who have reached an intellectual status after which
any further progress seems impossible. What is
more lamentable than a self-satisfied professional
man, who fancies that he has nothing more to learn?
Unfortunately he is no exception to the universal
law, and if there is no advance in his mental con-
dition, there will be recession.

A principal, if not the principal, cause of human
unhappiness is the mental unrest, which is caused by
the unsatisfied craving for the exercise and develop-
ment of our God-given intellectual powers. This
craving is born in aU mankind, it has been called
the divine unrest, because it leads man ever to
struggle toward knowledge, toward righteousness,
and toward freedom. Only the minds that have
freed themselves by powerful and regular exercise of
their own functions can shake off the shackles of
superstition and the bonds of fear. Only minds so
disciplined can be at rest and await with calmness
the unfolding of fate, can bear with fortitude the
struggle with their own limitations, and the in-
creasing bodily infirmities which tend to occlude
their vision and thwart their best efforts. Of such
a mind the good Sir Edward Dyer said three hundred
years ago: " My mind to me a kingdom is. " Nor is
the development of the highest type of mind possible
without a healthy and vigorous body. Nor can this,
on the other hand, be developed without persistent,
careful, and properly regulated exercise. In other
words, leaving out of consideration those human
anomalies whom we call geniuses, there is no way
that a man can fit himself to do good work, either
mental or physical, except by a thorough, painstaking
development of his mental and bodily powers.

Unfortunately the average man leads, strictly
speaking, no intellectual life. He does not really
think, he docs not read anything that requires mental
exertion, he does not study. And if we turn our
thoughts to the gentler sex what do we find? A
remark of Harriet Martineau's that the poor health
of American women was due to the vacuity of
their minds, was unquestionably in a measure true.
This was made, of course, some years ago, before the
proliferation of the female college, and the entrance
of women into the professions, etc. On the other
hand, an editorial in a leading medical joursal about
a year ago, in commenting upon the comparative
sterility of American women, says: "But with her
growth in brain power, she hasdeclined in physique."
To this statement the writer takes unqualified ex-
ception. American women in our day have smaller
families than their ancestors it is true, but proof is
entirely lacking that they are of inferior physique,
and their comparative sterility is due chiefly to an
improper and unphysiological avoidance of concep-
tion. This is not to say that there are not numerous
cases of nervous breakdown amongst women,
educated and uneducated, from overstudy, over-
work, etc. However, the percentage of American
women injured by overstudy must be inconsiderable
compared to the whole number of women of child-
bearing age.

The faulty methods of education now prevalent
are but too obvious and there is no question about
the handicaps which bear upon every woman who
undertakes to develop her mind. Nor can the ex-

July 1 6, 1904]

MEDICAL RECORD.

periment of giving a woman a. man's education be
successfully carried out in general, unless girls shall
be fitted for the contest by a better heredity and a
more physiological method of life. They must
develope their muscles and their lungs and live more
in the open air in childhood, and grow up without
the impediments of corsets, high-heeled shoes, tight
clothing and similar abominations, which cramp and
distort their growing members, itnpair their diges-
tions and lay the foundation for the nervousness,
dyspepsia, and the numerous bodily infirmities of
after years.

What women suffer from chiefly is want of
physical development. Had the}' man's muscu'ar
strength they could easily outstrip him in mental
acquirements, for at least the first few years of life,
by reason of their quicker and more elastic minds,
their greater devotion to their dutes and their
greater freedom from dissipation and immorality.
The mistake that our educators have made is to take
advantage of the girl's willingness to work her
intense love of approbation and her more rapid
mental expansion, which is commensurate with her
rapidly developing body, at the age of puberty, to
force her along too fast without regard to the con-
sequences. A woman's bodily health will be as
surely benefited as a man's by a thorough intel-
lectual development, but she is more easily injured
in the process because she is without any question
the weaker vessel.

I had begun to hope that the once prevalent notion
hat a man cannot be learned and physically strong
at the same time, was becoming passe, and yet in a
book on health copyrighted last year the following
appears: "It is an error also to think that great
muscular development is desirable in a brain worker.
The two are incompatible.' ' This is one of the hoary
fallacies which have encumbered medical literature,
and misdirected medical thought from time im-
memorial. One would fancy it to have been
originally the ipse dixit of some lazy and ill-developed
medical writer, who having no muscle himself and
being too indolent to acquire any, soon proved to his
own satisfaction the undesirabilit}^ of having any.
And subsequent medical writers have slavishly fol-
lowed this erroneous li.ght, as they have many others.
There was a kindred notion prevalent a generation
ago from the tj'ranny of which we have by no means
entirely escaped, viz., that a man is born into the
world with a certain fixed amount of energy, which
he is at liberty to expend in any way he chooses, but
cannot replenish; so that if our physical side is
developed, our mental must be dwarfed. Can any-
thing be more absurd, or more at variance with
nature's well known laws? And yet, I well remem-
ber a professor of philosophy, whose name is known
on two continents teaching that very doctrine to his
class, of which I was a member, about thirty years
ago; and there are many prominent teachers,
preachers and medical men, who believe or affect to
believe the same fallacy to-day.

I remember reading in my boyhood in an excellent
family paper called the Evangelist, this same false
doctrine, which made a deep impression on my
youthful mind and gave me serious doubts as to
whether it was right for me to work in the garden in
conformity with my father's commands, because it
seemed a serious thing to impair my chances of
acquiring an education, merely for the sake of
raising a few vegetables. And it also filled me with
consternation to reflect that this vigor or energy, which
it was assumed that we must carefully conserve for
the development of our brains, might be so easily
dissipated, and could not be expended at the same
time on both bodily and mental exercise any more
than one can both eat his cake and keep it.

That the Evangelist meant well in general on
matters of hygiene was evidenced by the sentiments
expressed in an editorial article upon washing the
feet, which also deeply impressed my boyish mind,
and I may say had a decidedly favorable influence
upon my habits. As I remember it now, the grava-
men of the article was that the feet should be washed
several times a week, instead of once; and the state-
ment was made that the skin of the feet has great
powers of absorption, and that the oflFensive matter
which is excreted through its pores would be re-
absorbed into the system were it not washed off.

This, so far as it goes, is true, and the advice is
sound and may be applicable to-day to at least some
of the readers of the Evangelist.

Even in those dark ages of sanitary science there
were glimmerings of the greatly aroused interest
which we at present note on this important subject.
And the fact that an influential religious paper and
the organ of a branch of the Presbyterian Church,
did not esteem an editorial upon washing the feet
beneath its dignity nor out of place in its editorial
columns, was an evidence of good sense, and re-
flected credit upon the editor. It showed further
that the readers of that paper, like the readers of
current literature to-day, wanted more light, per-
haps I should say needed more instruction, upon the
proper methods of living.

No one in our time who reads the newspapers or
who attempts to keep abreast with the tendencies
of modem American life, can fail to notice the ever-
widening interest displayed not alone in athletic
sports, but in all matters in any way pertaining to
bodily health and development. This is the day of
the ph3^sical culturist in all his forms and with all
his or her different theories, appliances, and maneu-
vres, by which vigor is to be attained, lost :nanhood
restored, dyspepsia banished, and the doctor avoided.
One "professor" offers for the insignificant sum of a
dollar to sell to anyone a book containing directions
which, if followed out, will save the purchaser from
the necessity of ever paying another doctor's bill.
There are all sorts of health foods and drinks ad-
vertised; all sorts of systems of diet, exercise, and
bathing are promulgated. One man teaches that all
food of whatever kind should be eaten uncooked.
Another denotmces the eating of any form of meat,
while a third instrvicts us that the consiimption of
nuts will give the most strength, which reminds one
of the butcher boy in David Copperfield, whose
preternatural strength was attributed to the beef
suet with which he annointed his hair.

This is the day of the man who advocates chewing
each morsel of food thirty-two times, once for each
tooth, said to have been a maxim of Mr, Gladstone's.
Of the man who goes without breakfast ; of him who
lives on eleven cents a day; of him who eats no salt,
and of him who cooks all the fruit he eats; of him
who never takes liquid with his meals, and of him
who advocates only one dish for dinner. We are
told to sit or lie naked in the sun, to wear only wool
next the skin; or linen, or silk, or cotton, according
to the predilection or self-interest of the adviser.

The disciples of an alleged school of hygiene in our
own State lie naked in the earth for several hours a
day. Some one in Chicago is just now preaching
against all forms of bathing, while other people
advise baths for the cure and prevention of every
form of disease. I have heard doctors in good prac-
tice advise wearing high-heeled shoes to "maintain
the integrity of the arch of the foot," while large num-
bers of people claim to have received benefit from
the Kneipp cure, a part of the regimen of which is
to walk barefooted in the dewy grass.

Perhaps the most revolutionary statement which

MEDICAL RECORD.

[July 1 6, 1904

I have met with lately is that of a "professor" who
guarantees to increase the stature of any one paying
him $10, and using his method, from two to five
inches. This seems to controvert the scriptural
statement that one cannot add to his stature by tak-
ing thought, but the world moves and our modern
"professors" are wonderful fellows.

One teacher advises against diaphragmatic breath-
ing; while others hold that it is the only physiologi-
cal method of respiration. Some would have us
exercise entirely without apparatus or implements;
others tell us that only by using the mechanical
devices in which they are interested can we make
true progress.

In Missouri, a State which will ever be famous
as the home of Osteopathy, a sect of dirt-eaters
has been started, and we are told that two
hundred and fifty students in the State Univer-
sity there have pledged themselves to eat only
twice daily for the next four months. A college
trainer last fall forbade the members of the foot-
ball team to wash in fresh water, forcing them to
perform all their ablutions in salt water; and so it
goes; I might, by a little research, indefinitely prolong
this somewhat grotesque list of more or less peculiar
performances, which are at present vaunted as con-
ducive, if not absolutely essential, to health and long
life. The above list, while incomplete and fragmen-
tary, serves to illustrate the point which I wish to
make, viz., that there is to-day a great and con-
stantly spreading interest in all matters relating to
the education and care of the body. Our colleges
spent last year in sports over $1,000,000. At Har-
vard $250,000 is to be spent for a stadium, from the
seats of which athletic games shall be witnessed by
about 40,000 people, while the president of the uni-
versity makes his annual plea in vain for a suitable
building in which to house adequately and make
available the books now in the college library. In
spite of the protests of a large part of the medical
profession, of the so-called leaders of thought,
and of many clergymen, professors, and thinkers,
the tove of athletic sports increases day by day.
How many learned opinions have I read in various
publications, lay and medical, about the evil effects
immediate and remote which must follow muscular
development, as surely, if not as speedily, as night
follows day.

Sir Benjamin Ward Richardson, an English medi-
cal writer of some note, said a few years ago that
he did not believe that there was living in England
at that time a professional or celebrated amateur
athlete over fifty years of age who did not pre-
sent symptoms of heart disease. Many of us can
remember a novel by Wilkie Collins called "Man
and Wife," written in great measure at least to decry
the then increasing love of athletic sports in Great
Britain. The late Senator Evarts is said to have
attributed his long continued good health to the fact
that he never took exercise. There used also to be
a great deal said about the brutalizing tendencies of
athletic sports. I remember my own father, after
giving a reluctant consent to my rowing in a crew
when in college, adding the admonition that I should
not, if I rowed, allow myself to become a rowdy.
Rowing men are not rowdies and athletic training
teaches self-command and moderation rather than
otherwise. How well I remember the words of a cel-
ebrated Boston surgeon of a generation ago, who told
his son that rowing in races would surely lead to
heart disease. This young man took little or no
exercise in college, while his chum was in the uni-
versity crew. Shortly after graduation from college,
the former pricked his finger in the dissecting room
and died of blood poisoning in a few days ; whereas the

rowing man is now alive and in good health, and has
practised medicine for nearly thirty years. I might
add that the brother of the first mentioned 3-oung
man was a foot-ball player in college, and is now
alive and well.

There have been unfortunately too few observa-
tions upon the subsequent careers of university crew
men, and it has been easy for medical writers, in dis-
cussing the subject, of the effect of exercise on the
heart, to fall into that spirit said bj- Huxley to be
engendered by the habit of speaking without the
expectation of a reply.

Of course there are writers and speakers of con-
siderable power and acumen who take the attitude
that if the facts do not fit their theories, it is so much
the worse for the facts. And there is also a habit of
the medical mind to forbid all practices of the safety
of which there can be a reasonable doubt, so that it
is easier to say do not do that, it may hurt you in
after years if not immediately, than to say candidly
I do not know what the effect of severe exercise will
be upon the heart. Fortunately a number of accu-
rate observations have recently been made upon
rowing men during training, and immediately after
the races, and now G. L. Meylan reports the results
of an investigation of the subsequent health of one
hundred and fifty-two Harvard oarsmen who rowed
in boat races from 1852-1892. He chose oarsmen
for investigation, inasmuch as there can be no ques-
tion of the severity of the exercise and its liability to .
produce immediate or remote effects upon the heart,
if any exercise can. His observations coincided with
those of Dr. Morgan, published in England in 1873.
This gentleman followed up two hundred and ninety-
four Oxford and Cambridge oarsmen who rowed in
University races in the forty years from 1829-69.
All this testimony shows that severe training and
rowing four-mile races does not produce heart dis-
ease, nor any other form of disease, and that oars-
men live longer and are happier, healthier, and the
fathers of larger families than other educated men
generally. And Meylan's investigation shows that a
larger percentage of these oarsmen have attained
distinction in letters and in the learned professions
than college graduates who did not row.

It shows that of the college graduates whose
names appear in "Who's Who in America," of the
average graduate the percentage is 2.1; of the Phi
Beta Kappa men it is 5.9, and of the oarsmen it is
8.3.

It is now up to these gentlemen who have said
such sweeping things about the injury which severe
exercise in general, and rowing in particular, may in-
flict upon the health, to produce some trustworthy
evidence in refutation of Dr. Morgan and Mr.
Meylan, or to confess, what the writer has all the
time suspected, that they were going to their
imagination for their facts, or relying upon hearsay
and unverified evidence in support of their precon-
ceived notions.

The observations of Dr. Morgan and Mr. Meylan
must be very comforting to many anxious parents,
who cannot keep their sons out of the college crews,
as well as to numerous writers and thinkers, who
have the welfare of their race at heart. For truly
one might as well try to make water run up hill as
to try to stem the present rage for athletics.

A brilliant writer said to me the other day, that
the world seems to be reverting to the old Grecian
loveTof physical prowess and admiration for the
body beautiful. Of course, we arc a long way from
this yet. Fancy our hollow-chested, pigeon-toed
women with their square hips and hour-glass waists
dressed as the Greeks used to dress. Fancy our
average business man with his protuberant paunch

July 1 6, 1904]

MEDICAL RECORD.

and skinny arms posing as a Greek hero. Sad as
this thought is, there is room for encouragement.
Our people, both men and women, are improving in
size, figure and carriage, and will continue to im-
prove. Whether the general intelligence and mental
development will ever reach as high an average
among us as it did among the Athenians, is quite
another question.

The great truth cannot much longer be kept from
the man of average intelligence and education, that
the condition of the general health is all important,
and the special diseased conditions are the exception
and are frequently the result of preventable causes;
and that in the majority of cases, when a man is
sick, the doctor can do him no good except with
advice, and that he must rely upon his own con-
stitution and his general health to pull him through,
if he is to get through.

The desire for strength, for bodily vigor and come-
liness, is perfectl}' natural and is born in all men and
women. As I have just said, it is impossible even
were it desirable, to stop the present interest in all
things athletic. On the other hand, now is the
opportunity for the real lover of mankind to confer
inestimable benefits upon the race by guiding and
directing them in the way that thej^ must walk, if
they would attain real physical excellence.

First, and most important of all, is to instil into the
receptive mind of the child the physical conscience.
He must be taught that it is just as wicked to injure
his health or to deprive his body of its needed rest,
recreation and exercise, as it is to steal, or lie to
commit any sin. The sins against chastity, so dis-
gustingly and alarmingly common, are also sins
against the body, not only because of the immense
risk of contracting venereal disease, but chiefly be-
cause no high-minded man, who truly respected his
body, would be guilty of such baseness.

The medical profession must take stronger ground
and be more outspoken against fornication, against
alcoholic drinks, against tobacco, against confec-
tionery, against gluttony, sloth and weak self-in-
dulgence — in fact, against all the physiological sins
which are daily and hourly committed in every part
of this broad land — in the palace of the rich, in the
hovel of the poor. But our duty is not done when
we have forbidden all these injurious things, we
must enjoin the physical exercises and the rules of
correct living, without which, the body cannot be
built up.

It is a great misfortune that the injunctions in the
Scriptures to keep our bodies in subjection and
mortify the lusts of the flesh, etc., should have been
interpreted to refer to all bodily pleasure, and
practically to all physical exercise and recreation.
I submit that we are commanded to restrain our
appetites, to curb our lust and contend with that
craving for stimulants and narcotics which is bom
in every man, but it is inconceivable that we are not
enjoined to educate and develop our physical powers
pari passu with our minds, and our morals, if we wish
to accomplish the moiety of the work in this world
of whieh the properly developed man is capable.

There is absolutely no attribute or power of the
human being, mental or physical, which does not
need development and exercise and prolonged use
before it can come anywhere near perfection. As
M. Georges Demeny says, "The essential of physical
education is voluntary motion." Massage, rubbing,
etc.. are at best only substitutes for voluntary exer-
cise of the muscles. President Faunce of Brown
University has said, in speaking of the "advantages
of disadvantage," that college boys take up athletics
to compensate themselves for not having been
brought up to work on a farm. In other words, not

having previously enjoyed an opportunity to acquire
the phj-sical basis necessary for years of mental
work and nervous strain; they take to athletic
sports in college with great avidity, and according
to the learned gentleman just quoted, in a measure
make up for their bodily deficiencies in this way.

You may tell me that certain men have achieved
greatness in spite of feeble and ill-developed bodies.
While this may be true in some cases, it is not
generally so. So far as known, the world's leaders
have, generally speaking, been of powerful physique,
and have also been men of simple tastes and ab-
stemious lives.

It has even been asserted that no man in this
country has risen to eminence in either the medical
or legal profession who has not at some time in his
life worked with his hands. I may be met by the
objection that strong and muscular men need much
physical exercise to keep their robust frames in good
condition, and that professional men cannot spare
the time for this. This objection is more apparent
than real, because all men whether muscular or not,
need some exercise to keep them well, and fifteen
minutes hard exercise in the morning beside the cold
bath, that every gentleman is supposed to take, is
enough to keep a stalwart body in good health.
Always provided, that the diet is strictly limited
and the man leads a correct life in other respects.

Whatever view of the spiritual life of man one
may take, a moment's reflection will show that
healthy and vigorous thinking cannot go on in a
diseased brain, nor in an improperly nourished brain,
nor in the brain of an overfed man. Every one
knows that if he eats too heartily he cannot think
clearly for some hours afterward, and he also knows,
if he has watched men at all, that inordinate feeders,
not to mention drinkers, are of apathetic minds and
slothful bodies. Whether the brain is a dwelling
place for the soul, or whether it is a secreting organ,
and "secretes thought as the liver secretes bile,"
there can be no question that it must be healthy and
well-developed, and a part of a healthy and well-
developed body, in order to do its best work.

All life, as it manifests itself to our senses, is char-
acterized by action, growth, recession, and decay.
There is never-ceasing change so long as life lasts.
It is also evident that under varying conditions,
plants and animals develop in ever-varying ways,
so man grows, reaches maturity, decays mentally
and physically, and dies. Is it reasonable to assume
that his complex and wonderfully formed body can
grow up and develop itself properly without thought
or care, on its owner's part?

No one disputes with a cattle-raiser or a horse-
breeder, or even a chicken raiser, about the advan-
tage, in fact the necessity, for applying the best and
most recent scientific knowledge to the development
and care of his charges. Even chicken fanciers make
their poultry exercise during the winter bj' hanging
their food nearly out of their reach, so that the
chickens must jump for it; or burying it under leaves
or straw, so that they must scratch for it. And
shall we not make a more thorough study of the
health and well-being of the human animal? Her-
bert Spencer says, "The raising of first-rate bullocks
is an occupation, on which men of education willingly
spend much time, inquirj', and thought; the bringing
up of fine human beings is an occupation tacitly
voted unworthy of their attention." However, his-
tory repeats itself, while the leaders of thought have
disdained to busy themselves with the proper nur-
ture and development of the human body, the nat-
ural instinctive love of strength and bodily vigor
which is bom in every Anglo-Saxon breast has reas-
serted itself, and, as I said before, the interest in

MEDICAL RECORD.

[Jiily 1 6, 1904

everything pertaining to bodily development grows
apace. And has grown and spread mightily during
the recollection of men yet young.

I should not like to leave this subject without a
few more words upon the mental aspect of education
in its relation to the physical. I say without hesi-
tation that the body cannot and will not reach the
highest state of physical health unless its mental
powers be also developed.

This paper is a plea for a symmetrical bodily and
mental development. Many men will acknowledge
that for the best mental health a strong and vigor-
ous body is needed, but I doubt whether it is gen-
erally appreciated that for the best physical health
a clear and well-educated mind is essential. In
fact, we speak of mental and physical health as
though they were two distinct states, capable of
existing separately. Nothing can be more errone-
ous. Health is the normal condition of bodily and
mental vigor, which every human being should
possess, and it is as absurd to speak of an
insane person as being healthy as to say that Stev-
enson was healthy when dying of consumption,
although his magnificent intellect was apparently
still undimmed.

We have Sandow's authority for the statement
that one cannot develop a muscle or set of muscles
without concentrating his mind upon those muscles.
He saj'S that " It (physical development) is the mind.
All a matter of the mind, the muscles really have a
secondary place;" and again . . . "A man
with strong concentration of mind will develop
quicker in the quality of his muscles, than will he
who cannot concentrate his mind upon the matter."

And these statements I believe to be true. I
believe also that the bodily and mental powers
are so interdependent and so indissolubly joined,
that neither can be exclusively developed without
injury to both. The body is not only a highly com-
plex machine, it is a growing, developing, ceaselessly
changing, living entity. If a locomotive is so con-
structed that the boiler will generate more steam
than the steam box can hold, there will be an explo-
sion as soon as there is a strain put upon the machine;
and if the boiler, the cylinders, and the steam boxes
are remarkably strong, while other parts of the
machinery are weak, there will soon be a breakdown
and the engine will spend most of its time in the
repair shop.

In this last condition is the highly educated man
who has neglected his body. He has brains, but not
brawn, and while he is capable of much good work,
he cannot endure prolonged effort, nor the constant
hammering which is necessary to achieve anything
really worth while, half so well as he might have
done had he more bodily vigor. But suppose in our
locomotive that the running gear is all right and
every part of the machinery of the first class, except
the boiler, no pressure of steam can be generated, and
the fine and complex machine is comparatively use-
less. In this state is the man with the great mus-
cular development, who lacks in mental force and
application. The stupid and brutal prize fighter,
without any book knowledge, is as much of a lusus
natural, a mistake and the result of one-sided train-
ing as the college honor man who breaks down about
the time he takes his degree, or shortly afterward ;
or the neurasthenic college woman, who divides her
time between reading Ibsen and languishing on a
couch. Perhaps there is no more striking illustra-
tion of the want of mental balance which comes in
many cases, at least from a want of bodily develop-
ment, than the hysterics of the popular preacher.
How much more real good would these men accom-
plish, if their fervor were tempered with moderation,
and their zeal with that sane and rational frame of

mind, that patience, courage, and self command which
hard and long trials of strength and skill engender,
and which we especially note in men of deep chests
and stalwart muscles. Not in men like the "lean
and hungry Cassius, who could not sleep o' nights."

We want the all around man who does not disdain
a good meal and pleasant society, a man who likes,
in moderation, pleasure and sport; in short, a well-
balanced man who works hard, plays hard, lives
moderately, sleeps soundly, and is, in short, jortiter
in re suaviter in niodo. A man who heeds the dic-
tates of his moral and his physical conscience, who
lets neither his mind nor his body deteriorate pre-
maturely by disuse on the one hand, or ill-judged
over-exertion or weak self-indulgence on the other.
Who is honest with himself and cultivates a spirit
of charity toward mankind and reverence toward
his Maker. Only in such men do we find the cheer-
fulness and contentment which come from work well
done. The poise of spirits, the serenity of a well
acting mind, and the subjugation and regulation of
the bodily instincts and passions, which are neces-
sary to a well-ordered manhood and a serene old age.

How often do we note nowadays in both men and
women, a condition of mental dyspepsia due to
improper mental pabulum, to overfeeding the mind
with fiction and sensational literature; which shows
itself in the all too prevalent disordered fancies and
silly theories, which the half-educated call wisdom.
There is a lamentable lack of a true sense of propor-
tion in the mental attitude of many teachers and
writers, partly due, I think, to their ovm ill-devel-
oped or pampered bodies.

It is a common saying of the day that educators
and clergymen are as a class lacking in judgment.
It is they who support and sympathize with the
quack and the irregular practitioner. It is they who
mistake hysteria for piety, effrontery for skill, and
a flattering tongue for true learning.

In closing, let me put in one word the great truth
this paper is meant to inculcate.

Struggle as we may against it, the conclusion is
unavoidable that work, steady, regular, persistent
work, both mental and ph}-sical,is necessary for the
average man; without it, he will not only not accom-
plish anything of value, but he will be miserable,
because while he may not be able to appreciate the
reason he will be abundantly sensible of the fact that
he is a failure. 1

Only the workers have tasted the sweets of living.
They have been happy because the)^ have

" Girded their spirits and deepened the streams
That make glad the fair City of God."

Our bodies, our mental faculties, our special senses
are all tools with which the indomitable spirit works.
These tools may be rough, badly forged, and badly
tempered, or they may be even, smooth, well forged;
and exquisitely polished; with which think you wil!
the best and most enduring work be accomplished!

Concerning the Practical Value of Recto-Romanoscopy

— S. Kelen discusses the value of the rectoscope recentl)
introduced by Strauss, in which the examination of th(
rectum is simplified by inflating that organ and th<
sigmoid flexiue with air. The method is particularlj
effective in ascertaining the condition of the rectum a
higher levels than those brought into view by the ordinan
instruments, and the author claims that it is possible t(
make a diagnosis of lesions in the ampullfe or the beginnin;
of the sigmoid flexure. He has also been convinced tha
the rectal tube introduced for the purpose of giving a hig'.
enema does not pass beyond the ampullee, and suggest
that the tube be introduced through this instrument afte
the latter has been inserted about 25 c.c. and the lam
removed. In this way the liquid is certain to get into tb
sigmoid flexure. — Pester medizinisch-chirurgisdie Presse

July 1 6, 1904]

MEDICAL RECORD.

A STUDY OF INTESTINAL PERFORATION
AND PERITONITIS IN TYPHOID FEVER.
WITH A REPORT OF THREE SUCCESSFUL
OPERATIONS, AND A STATISTICAL INVES-
TIGATION OF 295 OPERATIVE CASES.*

By WILLIAM D. HAGGARD, M.D..

NASHVILLE. TENN.

PROFESSOR OP GYNECOLOGY, MEDICAL DEPARTMENT. UNIVERSITY OP TEN-
NESSEE, FORMERLY PROFESSOR OF GYNECOLOGY AND ABDOMINAL
SURGERY. UNIVERSITY OP THE SOUTH; GYNECOLOGIST TO THE NASH-
VILLE HOSPITAL; FELLOW OP THE SOUTHERN SURGICAL AND GYNECO-
LOGICAL ASSOCIATION; MEMBER OF THE WOMAN'S HOSPITAL SOCIETY
OF NEW YORK, ETC.

The immortal phrase" The resources of surgery are
rarely successful when practised on the dying" has
been most wonderfully negatived in the operative
treatment of perforative peritonitis in typhoid fever.
Surgery has reclaimed many otherwise irremediable
conditions. It was a great step when Sims siiggested
abdominal section for intestinal perforation for gun-
shot wounds, which daily rescues many victims. It
was a great step when Fitz and McBurney taught
us the frequency and means of relief of perforation
of the appendix, which has saved so many valuable
lives. But it is a still greater achievement to be able
to succor the hopeless sufferer from the onslaught
of a fatal peritonitis from perforation in typhoid
fever.

The possibilities of this latter achievement, how-
ever, have not yet been appreciated keenly enough
by the profession. It is almost a score of years
since Mikulicz did his first operation in 1884. Since
that time, I am only able to collect, from all sources,
by the most diligent search through the literature,
together with cases personally communicated, 295
cases that have been subjected to operation up to
May I, 1903. Granting that there have been as
many, or twice as many, cases that have not been
reported or found, I still claim that the total sum is
pitiably meagre. For we have only to reflect that
an estimate of 500,000 cases a year occur in this
country alone, and with a general death rate of 10
per cent, to 15 per cent., 50,000 or 75,000 souls perish
annually from this terrible scourge which we daily
implore families and municipalities to prevent.

Osier says that one-third of the deaths from
typhoid fever are due to intestinal perforation.
Taylor thus estimates that 25,000 deaths occur
yearly from this accident. On the basis of a possi-
ble 30 per cent, recovery by operative interference,
he further concludes that 7,500 persons perish in the
United States each year who might be saved.

The reasons for this are complex. They are partly
preventable, and partly irremediable at this time.
One explanation is the reluctance with which the
practitioner invokes the aid of surgery in the pres-
ence of such forbidding general symptoms. Another
is the likelihood of death even with the operation;
but the greatest of all is the great difficulty of mak-
ing a positive diagnosis in the early stages. This
difficulty will always exist with our present methods
of diagnosis. It inaj^ be considerably lessened by a
proper appreciation of even the suspicious abdomi-
nal symptoms, intelligent alertness, and frequent
examination.

Perhaps the greatest stumbling-block is the clas-
sical picture of perforation which needs erasing: the
drawn, pinched features, pointed nose, profuse
sweat, cold extremities, rapid, feeble pulse, short,
sighing respiration, distended and motionlesss abdo-
men, restlessness and delirium — these are the late
and lethal manifestations of peritonitis, and not of
perforation.

I regret that we have not as characteristic a pic-

*Read before the American Association of Obstetricians
and Gynecologists, Chicago.

ture of the early symptoms of perforation. Some
cases are fairly typical, but others presenting such
presumably typical symptoms are found not to have
perforation. Again, peritonitis may be the first
symptom. Given a man in the third week of a mild
attack, without abdominal symptoms and pursuing
a regular course, who is suddenly seized with an
acute, paroxysmal pain in the right lower quadrant
of the abdomen, that causes him to cry out, that is
unrelieved by ordinary measures, followed by col-
lapse, subnormal temperature and rapid pulse, which
are succeeded by a rise in temperattire in a few hours,
associated with continued pain, considerable tender-
ness and right-sided rigidity, together with a rapidly
increasing leucocytosis, the diagnosis of intestinal
perforation is reasonably certain — not absolutely —
but surgically. All such cases should be operated
on as quickly as possible.

The difficulty is that all cases do not present this
typical grouping.

No abdominal symptoms.'objective or subjective,
occurring in typhoid fever, should be considered
trivial. Pain is usually the first note of alarm.

My study of the reported cases develops that c*
sudden severe colicky pain is present in a large
majority of cases. Collapse is an infrequent at-
tendant of perforation, and was present in only about
6 or 7 per cent. Fall in temperature was not con-
stant, but rise in pulse was rather uniform. Of the
physical signs, tenderness (sensitiveness) was found
to be the most constant. And studied in the order of
their development, and more especially their signi-
ficance, it was found that pain, then tenderness, then
rigidity, and then localization in one spot occurred.

Persistence of symptoms serves to distinguish
them from colic which should disappear in a few
hours or change its location.

Recognizing the difficulties and limitations in
diagnosis, exploratory incision should be regarded as
a necessary and final aid in diagnosis.

The facts about intestinal perforation, which I
have deduced from a statistical study of the cases,
may be summarized as follows:

1. It occurs more often in men than women —
80. 9 vs. 19. 1 per cent. It is, like hemorrhage, rare in
children.

2. It occurs in about 2.5 per cent, of all cases of
typhoid fever.

3. 3.31 per cent, occur in the first week; 20.19 Per
cent, in second week; 38.94 per cent, in third week;
14.90 per cent, in fourth week; 9.13 per cent, in
fifth week; 5.75 per cent, in sixth week; 7.21 per
cent, from seventh to eleventh week, and has been
observed as late as the one hundredth day (Cursch-
mann). Holmes operated on one case after four
months.

4. It naturally occurs more frequently in severe
attacks, but may occur in mild attacks, and it may
be the first real symptom of so-called walkingtyphoid.

5. It occurs in the ileum in 95.5 per cent., usually
in 18 inches of csecum (Osier), always in 3 feet
(Loison). In the large intestine in 12.9 per cent.,
and is most often situated in the ascending, trans-
verse, and descending colon, sigmoid and rectum, in
the order named. It may occur, also, in the ap-
pendix, Meckel's diverticulum, and jejunum.

6. The perforation is single in 84 per cent. There
may be two or more, and in one case there were
twenty-five (postmortem). Cases with diarrhoea
and tympany are more likely to have perforation.
Six out of thirty cases occurred with hemorrhage.
(Osier.)

7. The death rate given by Murchison is 90 per
cent, to 95 per cent. Osier says he could not recall a

9°

MEDICAL RECORD.

[July i6, 1904

single case in his experience that had recovered after
perforation had occurred.

Occasionally the careful observer and con-
scientious surgeon, in his earnest effort to interpret
signs aright, and to operate before general peritonitis
has rendered the patient hopeless, may open the
abdomen to find no lesion whatever. This has been
done by the most expert, and will sometimes happen
until we devise some absolutely earl 3' sign. Com-
monly the patients progress and get well, as though
nothing had been done to them. It has demon-
strated the fact that these patients will bear the
surgery necessary to make a positive diagnosis in
suspected, but doubtful cases. Indeed Finney ad-
vises exploratory laparotomy under cocaine anaes-
thesia in suspected cases. To be sure, there is some
chagrin attaching to a seemingly unnecessary
operation, but it is much better to do such an opera-
tion upon a mistaken diagnosis, than to neglect to do
it upon a case that demands it.

To avoid this embarrassment Connell has in-
geniously devised recently a procedure based upon
the fact that sulphuretted hydrogen will, when
passed through a solution of acetate of lead, turn it
black by the formation of sulphide of lead. He
proposes, as the result of animal experinjentation, to
introduce an ordinary trocar and cannula into the
lower part of the abdomen in suspected cases of
intestinal perforation, to insufflate filtered air, which,
mixing with the intestinal gas in the peritoneal
cavity, is allowed to escape through another cannula
at the upper part of the abdomen, into a solution of
acetate of lead. If sulphuretted hydrogen be
present as a result of a perforation, the reaction will
take place.

Other experiments were made by injecting sterile
salt solution, and withdrawing it in from three to
twelve hours. Where the intestine had been in-
tentionally punctured or opened, and the salt solu-
tion allowed to mix with the fecal extravasation,
when it was withdrawn, ammonia could be detected
by Nessler's reagent, indol by sodium nitrate and
sulphuric acid and proteoses by the biuret test.

-None of these tests were positive in air or fluid
injected and recovered from the normal peritoneal
cavity. The method appears to be harmless, but
lacks additional confirmation as to its uniformity and
reliability. Meanwhile the diagnosis of perforation
must rest upon the minutest scrutiny of suspicious
signs, which, if deemed reasonably certain, should
demand an exploration; or upon the advent of
peritonitis, it should be imperative. The mild and
early symptoms are the important ones. The severe
sjrmptoms usually mean peritonitis.

t is surgically immaterial whether a perforation
exists or not if there is peritonitis. It is more apt
to be localized if there is no great extravasation.
Peritonitis in typhoid fever may be due to migration
of bacteria through the intestinal walls without
actual perforation, as evidenced by the number of
cases of peritonitis without perforation. It may
result from ruptured abscess of the liver, rupture of
the spleen, or of the gall-bladder or ducts, of the
mesenteric glands, appendix, and from gangrene of
the intestine caused by thrombosis.

The surgeon should stand in close relationship
with the physician in typhoid fever, as is now the
quite general custom in appendicitis. Gushing
advises that he should be consulted at the first indi-
cation of a localized peritonitis, and should perfora-
tion and extravasation occur, operation may be
undertaken without delay. 0.sler advises — "In
doubtful cases patients should be given the benefit
of the doubt and operation urged {The Lancet, Feb-
ruary g, igoi). Keen says "We should operate in

practically every case of perforation, unless the con-
dition is such that recovery is evidently hopeless."
(Journal of the American Medical Association, Janu-
ary 20, 1900.) Further, "after perforation has
occurred operation should be done at the earliest
possible moment, provided that we wait till the
primary shock, if any be present, has subsided.''

Case I. — My first case was in 1898, and reported
in the Transaction of the Southern Surgical and
Gynecological Association, 1899. Woman, nineteen
years of age, married eight months. In the third
week of severe typhoid fever with delirium, a tender
swelling developed in the right iliac region, that was
quite frank and prominent. When I incised it, the
gas and pus were forcibly ejected from the tension
in the sac. It was larger than a cocoanut, and
well walled off. The cavity healed in about three
weeks. The fever progressed with increasing sever-
ity and she died fromtoxfemia, three and a half weeks
after operation in the seventh week of the disease.
Widal's test positive. No autopsy. This case is
ver)^ similar to case 122, in Keen's list, reported by
Munro, which is recorded as a surgical recovery.

C.\SE II. — July, 1901. Boy, nine years of age
with mild typhoid fever, with some tenderness and
slight rigidity in the right iliac region that inclined
us to diagnosis of appendicitis. On the nineteenth
day he developed symptoms of localized peritonitis in
the right iliac region. Incision over the slightly dull
tumor at my clinic at the University of the South re-
vealed a fairly well walled-off area, the walls of which
were almost in apposition, the sides and bottom of
which presented three perforations; two appeared to
be in the innerwall, composed of small bowel, and one
in the outer wall orcolon; no pusbut a slight amount
of fecal fluid. All of these openings were sutured
and drainage established. A fecal fistula appeared
on the third day and persisted. He remained in bed
with typhoid symptoms and temperature for ten
weeks, and developed a left suppurating parotid. I
closed the fistula eighteen months afterward with
success.

These two cases were examples of the two types
of local peritonitis: perforation with'abscess forma-
tion and perforation with walling-off by adhesive
peritonitis, the perforation still patent.

C.\SE III. — Example of free perforation. Male,
aged thirty-four, in previous good health. He was
under the care of Dr. Sugg of Beachville, Tenn. On
October 8, 1903 (the twelfth day of the disease), the
temperature was 101°, instead of 100° as usual; the
pulse 92 instead of 72 or 80. An enema was given,
which acted well. At 11 o'clock the patient was
seized with sudden, severe colicky, abdominal pain-.
The pain abated somewhat, and when the doctor
reached him the temperature was normal and pulse
72. An enema was ordered and a turpentine stupe
applied. At this time there was little or no tym-
panitis, nor had there been in the entire progress of
the case. At 2 p.m. — three hours after the onset of
pain — the patient was still suff'ering with considera-
ble abdominal pain. There was slight tenderness
over the abdomen, which was most pronounced in
the right lower quadrant, extending a trifle to the
left of the median line. There was slight abdominal
distension. The temperature had risen to 104° and
pulse was 120. The face was anxious and appre-
hensive.

Dr. Sugg made the diagnosis of perforation. The
patient was ten miles in the country, and I reached
him seven and one-half hours after the onset of pain.
The conditions were unchanged, except that the tem-
perature had receded to 1 o 2 . 6° and the pulse was 116.
The sudden onset of acute abdominal pain in the
second week of a mild case of typhoid fever, followed

July 1 6. 1904]

MEDICAL RECORD.

by rapid rise in temperature and pulse-rate, the
anxious facies, the undiminished pain, the distention,
tenderness, and rigidity indicative of beginning peri-
tonitis, pointed quite strongly to perforation.
Although it was after night-fall, in a three-room
farm house, with no facilities for operating, yet in the
face of an otherwise fatal issue, and with the
patient's consent, preparations were made as rapidly
and completely as possible, and abdominal section
was made eight and one-half hours after the onset of
pain. When the peritoneum was opened in the right
semilunaris, a quantity of free, odorless, chyme-like,
yellow fluid made its escape. The caecum was at
once located and pulled up with the appendix for
inspection. The latter was found to be normal.
The adjacent ileum was deeply injected and pre-
sented a modena-color, and was slimy from being
bathed in the pea-soup effusion. It was passed
between the fingers for a few inches, and at about
twelve inches from the caecal extremity the per-
foration was found. The actual opening was small
and situated in the center of an indurated area about
as large as a five-cent piece. Upon manipulation there
exuded from the perforation yellowish intestinal
contents corresponding in color and odorlessness to
the free fluid found in the cavity. The knuckle of
gut containing the perforation was surrounded by
gauze pads, and the indurated area containing it was
inverted by five Lembert sutures of small silk. A
second layer was placed above and between the first
row and at the angles.

The sutured area was temporarily surrounded with
gauze and replaced in the cavity pending the
peritoneal toilet. As much of the pea-soup material
as possible was sponged out of the right iliac fossa
and the pelvis, and then the cavity was filled with
salt solution poured from a pitcher. The small
quantity that was prepared in the limited time was
exhausted before the cavity was at all clean, and
here came the greatest technical difficulty of the
operation. There was an abundance of boiling
water, but no cool boiled* water. A by-stander was
sent to the spring with a clean pitcher for water
which had to be dipped up, this delayed us some
minutes. I thought the unsterilized water was less
harmful than the known septic fluid. The irrigation
was satisfactorily completed, and the patient turned
on his side and all fluid allowed to run out. The
gauze around the injured intestine was replaced by
two clean gauze strips which met under the perfora-
tion, and were so disposed as to bring that portion just
under the incision. A gauze strip was introduced in-
to the bottom of the pelvis, and another in the right
flank, and the wound closed by interrupted worm-
gut sutures. The entire operation comprised th'rty-
eight minutes, including the delay.

The pulse at completion was 96, and not above 84
on the following day. The temperature did not ex-
ceed 100.8°. On the second night the temperature
reached 102°, and the pulse, after the excitement of
being told of his serious condition by his wife, went to
120. With that exception the pulse did not go above
108. The facies during the second night was
anxious, the legs flexed, the respiration difficult,
nausea was persistent and vomiting frequent and
offensive. There was considerable distention and
severe pain, requiring ^ gr. morphine, with marked
subsidence of the symptoms. Flatus was passed in
considerable quantity toward morning and the
patient was more comfortable, but the mind was not
dear. The gauze was removed in forty hours, being
loosened by hot salt solution introduced by a glass
catheter, which was allowed to run into the abdomen
until it came back clear. The bowels moved well
after this, and the case progressed satisfactorily with

a morning remission to ioo° and an evening ex-
acerbation to 101°, pulse varying from 84 to 96.

On the twenty-second day of the fever and the
tenth day after operation the temperature remained
normal for two days and the stools appeared normal.
On the twenty-fourth day he had a relapse, the
temperature reaching 102.6° and the pulse 108. The
tympany returned, rose-spots again appeared on the
chest and abdomen, and the stools became loose and
offensive. Defervescence occurred in the fifth week,
the temperature returning to normal, and the belly
became scaphoid. The patient became brighter and
hungry. He was again considered convalescent, but
after three days of convalescence he became somno-
lent and listless; the urine diminished in quantity
and was found to contain albumin in considerable
quantity. He was greatly weakened, but was able to
leave his bed in the eighth week and has remained
well since.

Technique. — Inasmuch as the usual site is near the
ileocsecal valve the right iliac incision should be
chosen. In cases of general peritonitis a central
incision is better. The ulcer when found, may be
trimmed or excised, or simple invertion suture seems
to be competent. The mattress suture has the
advantage of only one knot for two threads. The
second row may be continuous to save time, and a
third may be added if it does not constrict the lumen
too much. Sutures may be transverse or longitudi-
nal. Care should be taken not to cut off too much
of the circulation when the ulcer is situated near the
mesentery.

The Cargile membrane is recommended for addi-
tional protection. Search should be made for other
perforations and any thinned areas inverted by
suture. Resection may be nractised if there is much
destruction, but the formation of an artificial anus
is best in the majority of cases in greatly debilitated
Subjects. Escher saved three out of four cases by
ileostomy. Copious irrigation is essential in extrav-
asation or general peritonitis. Sponging out is bet-
ter in localized and walled-ofif areas.

Drainage by the vagina is preferable in women.
Lumbar punctures and drainage by tube and gauze
is expedient in men. Most of the wound may be
left open with advantage and the damaged area cof-
fer-dammed with gauze and located very near the
incision. To facilitate drainage and localize infec-
tion in the less vulnerable pelvic peritoneum, instead
of the fatally absorptive diaphragmatic area. Fowler
advocates sitting the patient up at an angle of 40
degrees. Murphy reported six cases — consecutive —
of general peritonitis (one typhoid) in which recovery
followed when this was done. I have for some years
been turning the drained cases of appendicitis on the
right side from the start with this idea in view.

Statistics.

Westcott collected 83 cases in 1897 (published by Keen)
with 16 recoveries, 19.36 per cent.

Tinker collected 75 cases in 1898 (published by Keen)
with 21 recoveries, 26.66 per cent.

I have collected 137 cases (published and unpublished)
with 43 recoveries, 31.31 per cent.

This makes a total of 295 cases, with 80 recoveries,
27.11 per cent.

Of this grand total only 246 were sufficienth'' com-
plete for purpose of study. Of this number there
were :

89 cases of free perforation, with 29 recoveries, 36 per
cent.

19 cases of localized peritonitis, with 9 recoveries, 47.3
per cent.

138 cases of general peritonitis, with 29 recoveries, 21
per cent.

There were 16 cases at Johns Hopkins up to 1901,
with 6 deaths, 37.5 per cent. Cushing had 11 cases
with 5 recoveries, or 45.5 per cent. He predicts that

MEDICAL RECORD.

Quly 1 6, 1904

the percentage of recovery will soon be from 50
to 60 per cent.

I feel that a saving of over 27 per cent, in all cases,
good'and bad, extending over a period of twenty years
is a most encouraging showing, and that 36 per cent,
in cases of free perforation should encourage us to a
more prompt diagnosis and the invocation of surgi-
cal relief to these otherwise hopeless subjects.

A more general appreciation and application of
the possibilities of operation for typhoid perforation
will not only be a great surgical triumph, but will
add many precious years to the span of human life.

IMPROVEMENTS IN ANESTHETIC APPARA-
TUS AND TECHNIQUE.

Bv JAMES T. GWATHMEY M.D..

NEW YORK.

AN/ESTHETIST TO GOUVERNEUR. NEW YORK SKIN AND CANCER, AND

THE CITY HOSPITALS.

In a progressive science like that of anaesthetics we
must constantly expect improvements. A few new
ideas and methods that have been tried and found

kept by the anaesthetist. The amounts given in sim-
ilar cases for the same length of time, and by differ-
ent methods, would also prove of inestimable value.

If the case is a diflicvdt one for the anaesthetist,
the pulse should be taken by the non-sterilized nurse.
There are many other reasons for an anaesthetic
chart in both public and private cases, but the above
are sufficient.

That Junker's Inhaler is not more often used in
our hospitals in operations about the head, is due,
in the writer's opinion, almost entirely to the idea
of giving chloroform through a closed inhaler and
mask with valves. Take the margin of a German
ether inhaler as a model for the face-piece, having
this perforated with holes around the inner margin,
and the rest of it made as an ordinary chloroform
mask. Covering this with two layers of gauze, and
using a two-ounce bottle with a stopper and catch
(instead of a screw stopper), we have a very simple
form of inhaler. If the small mask is fovmd to be in
the way, the metal tube may be substituted and
used also as a retractor, the anaesthetizer thus becom-

ANESTHETIC CHART.

.7S0_

AnnANOco av on cwathmct.

Bit Dr..
Heart _
lungM _
Unne

Patients.
Address _

Ag»

Sex

WeilU^

CotnpUcaiioru .

-,i

I-'

FIRST

HOUR

SECOND

HOUR

THIRD

HOUR

soo

140
ISO
190
100
•0
80
TO
60

■

s
5

Before DiuiBf

Rnnni ^ Hmira

After

___

. Pupa* .

Vooitiaf -

Toul time uienbMia «ad opermtloo. Roan

Prom eompletioa ul opontloa l^ coasciooscet^ Mloutc* ^
Aorithctiw I

. SliBoUot* aeedcd .

musHio ■« THC KMT-sCHiifwn CO. Ntw Tonhu. s. a.

of value are herewith oflered lor what they may be
worth. In order to facilitate the acquirement of
more exact knowledge by everyone concerned, an
anaesthetic chart should be in every hospital, regard-
less of the method or anaesthetic used.

The surgeon would thereby get more exact data
on all cases, and the hospital interne be compelled
to give closer attention to details. In all chloro-
form anaesthesias the pulse should be taker every
five minutes, the time recorded at the top of the
chart and the rate by a dot on its respective line.
This should also apply to all chloroform mixtures,
as the A. C. E. (alcohol 1 part, chloroform 2 parts,
ether 3 parts) or C. E. (same as above with the alco-
hol left out). During ether narcosis, the pulse-taking
would depend entirely upon the patient's condition
and the nature of the operation, but, as a gen-
eral rule, the pulse should be recorded as above.
The charts are arranged in book form with a carbon
sheet, so that one chart may either be placed on file
(if a hospital case) or given to the surgeon, the other

ing an assistant to the surgeon, instead of hampering
him. I have used this inhaler in over fifty very
difficult cases, most of them over three hours and
two of them over four hours in duration. Several
of these cases were athletic alcoholics, such as give
most trouble to the anesthetist, but it has never
failed to .give satisfaction. For extirpation of the
tongue and similar operations where the surgeon
prefers an analgesic rather than an anasthetic state,
when a cough or swallowing movement materially
aids in clearing the throat, this level of narcosis can
certainly be maintained by this method more easily
than b}- the drop method.

The Gwathmey chloroform inhaler then (a modi-
fication of Junker's) consists of a two-ounce bottle
with a metal tube running to the bottom, and con-
nected on the outside with the afferent tube from
the hand-bellows. The efferent metal tube s'mply
perforates the rim of the bottle, and is connected
with the mask by another rubber tube. The bottle
is graduated to hold 8 drachms, which is usually

Jtily 1 6, 1904]

MEDICAL RECORD.

sufficient, although in the case of alcoholic subjects
an extra 4 drachms should be added. On pressing
the bulb, air is passed through the anaesthetic and
the chloroform vapor carried to the mask by the
efferent tube. If at the end of six minutes the
patient is not unconscious, additional chloroform
should be sprinkled upon the mask. While it is not
the intent'on to go into details in an article of this
kind, it may be well to state here that after the
patient has become quite unconscious, "only small
doses are required to maintain anaesthesia, as it is

Fig. I. The Gwathmey oxygen-chlorolorm inhaler.

necessary to introduce only so much further chloro-
form as is required to replace what is lost by exhala-
tion, and thus to maintain in the blood that per-
centage of chloroform which at first was required to
induce anassthesia." (Luke.) A metal stop-cock
has been placed on the efferent tube, and by turning
this, the percentage of chloroform vapor can be
easily regulated.

Whenever possible, the nitrous oxide-ether se-
quence should be used as a preliminary, the change
to chloroform being cautiously begun with the

field). Many surgeons have recommended this
method whenever chloroform is indicated. If it is
necessary for the anaesthetist to keep the throat
clear of blood, etc., during the operation in addition
to maintaining the level of anaesthesia called for in
order to have the use of both hands, he simply drops
the buib on the floor and makes the necessary pres-
sure with eith-er foot. The meial tube and mask are

Fig. 3. Combination gas-ether narosis.

to be Sterilized before and after every operation. If
any chloroform is left ir the bottle, it should be
thrown away.

From experiments recently made by myself with
this apparatus — using a closed inhaler — and killing
between 50 and 100 cats. I can state that a mixture
of oxygen and chloroform is three times as safe as
one of air and chloroform and almost as safe as ether

Pig. 2. Bulb on the floor — giving the ansesthetist the use of both hands.

return of the reflexes, such as a cough or swallowing
movement. When the above method is used,
"chloroform anesthesia may be maintained with a
nsk to life which is so small as to compare very fav-
orably with, if it does not actually reach, that of
ether ana;sthesia" (Hewitt). If at any time, the
patient is troubled with shallow breathing, a few
drops of ether on the mask will quickly remedy this
condition. "Overdosage is less apt to occur with a
Junker's Inhaler than with the drop bottle" (Blum-

FlG. 4. Combination oxygen-ether narcosis.

and air. Details regarding the results of these
experiments will be given in a subsequent article.

Since the introduction of gas-ether inhalers into
our hospitals, the criminal carelessness with which
they are treated deserves attention. Because they
are on the anaesthetist's table the surgical nurse or
whoever may have charge of the instruments seems
to think that it is unnecessary to give any more
attention to them than to an ether or chloroform
bottle. Doubtless many cases of pneumonia have

MEDICAL RECORD.

[July 1 6, 1904

already been contracted from these septic inhalers.
All the metal parts of the inhaler should be boiled,
and all rubber parts should be treated with a car-
bolic solution, 1-20, and dried carefully. They
should not be put together until the anaesthetist is
ready to use them again. In all operations where
the anaesthetist may come in contact with the sur-
geon or his instruments, the inhaler and all instru-
ments of the anaesthetist should be sterilized, a ster-
ilized towel should be placed over the anaesthetist's
table and sterilized gauze wrapped around the chlo-
roform bottle and ether can. If the above is carried
out, the anaesthetist may with propriety "wash up"
and put on white sterilized gloves, but otherwise it
is nonsense.

As the valves of the Gwathmey gas-ether inhaler
are absolutely independent of each other, two com-
binations are possible with this inhaler, that cannot
be given with any other. With the ether chamber
turned on full, and the expiratory valve on the face-
piece open, keeping the gas-bag connected with the
gas tank and maintaining a positive pressure in the
bag, thus allowing the gas to flow through the ether
chamber, a very satisfactory combination gas and
ether narcosis can be given. At every third or fifth
breath remove the mask and allow an intake of
fresh air. A soft, easy breathing, with a slow pulse,
is thus secured and maintained. This anaesthetic is
indicated where for any reason it is desired to abolish
the reflexes and yet give as little ether as possible.
By this method a deeper anaesthetic than gas and
air or gas and oxygen is secured, but not as deep as
ether alone. The cases must be selected — middle-
aged women and feeble men can be easily carried
several hours. Athletes and alcoholics will not take
it so readily. It requires close attention, for as soon
as the mask is removed, the patient recovers, and if
properly given there will be no nausea or vomiting.
iiRxxx of ether every five minutes is usually suffi-
cient.

The combination of oxygen and chloroform
has been given thousands of times by placing
a tube from the oxygen tank under any ether
mask, but this means unknown quantities of
both oxygen and ether. By allowing the oxygen
to flow continuously through the ether chamber (as
in the gas and ether combination) the oxygen carries
with it the ether fumes. This anesthetic is indi-
cated in all conditions of shock and collapse. I have
given this for over one hour and a half to a patient
with intestinal perforation. The radial pulse could
not be felt at any time before or during the opera-
tion, but the pulse continued good, and the general
condition was better after the operation than before.
In ordinary cases the pul^e will go as high as 115 or
120 with the commencement of oxygen, but will
drop back again to normal in five to ten minutes,
and so remain.

For the tri-sequence, one should use^lthe gas-
sther sequence as a preliminary, and then ether
in the usual way. If the operation lasts over
two hours, continue the anaesthetic as in the gas-
ether combination. In other words, in all long
operations, the last part should be more of a gas
than of an ether anaesthesia. By. this method the
patient is thoroughly conscious at the end of the
opc-ation, and there is always less nausea and vomit-
ing.

Too little attention has been paid to this some-
times most distressing part of an operation. A
prominent surgeon said, "The only way to prevent
this, is to cut the patient's head off." But in over
90 per cent, of all cases this condition can be pre-
vented by the observance of the following well-
known but usually neglected rules: (i) Keep an open-

air way at all times (not an easy thing) by keeping
the head to one side and the jaw pressed well for-
ward. (2) As soon as the anaesthetic is removed,
replace the ether odor by any other stronger smell,
salts or cologne (if not too sweet). This is on the
theory that the olfactory nerve is largely responsible
for at least the initial symptoms, and results would
seem to indicate that this is correct. More than
merely "not to kill the patient" is demanded of the
anaesthetist of to-day. Close attention to technique
and nicety in every detail have elevated anaestheti-
zation to the place it now holds.
124 East Sixteenth Street.

HAY -FEVER, SOME PRACTICAL SUGGES-
TIONS AS TO ITS MANAGEMENT AND
TREATMENT.

By RALPH WAIT PARSONS. M.D..

OSSINIMG, N. T.

Of the many diseases to which man is heir, few are
more intractable, and as regards the results of treat-
ment, few more unsatisfactorj', than the condition
commonly known as hay-fever. Particularly is this
the case when the patient either declines, or is un-
able to avail himself of the services of a physician
who is skilled in the treatment of the diseases of the
nose and throat.

Some patients with hay-fever do not experience
much inconvenience from their malady; but, in a
large number, the discomfort and actual suffering are
so great as seriously to interfere, at times, with their
business pursuits and social enjoyment.

Hay-fever being essentially a chronic affection,
time and patience are important elements in tht
treatm.ent of the disease.

I feel confident that if the hygienic and thera-
peutic measures herein advocated are adopted,
many patients suffering from hay-fever will find
considerable relief from the annoying symptoms of
the disease, and some will be permanently cured.
The patients should be urged to carry out the
physician's directions carefully and systematically,
in order that the best results of treatment ma}' be
obtained.

A few words as to the predisposing causes of the
disease. It is generally conceded that there are
three conditions which are necessary for the pro-
duction of hay-fever, namely: (i) An irritant to the
nasal mucous membrane, such as pollen, dust, etc.;
(2) a neurotic habit; (3) an obstructive lesion in the
nose.

It is not my intention in this paper to enter into
the discussion of the pathology or symptomatology
of hay-fever. These have been so thoroughly de-
scribed in textbooks on the diseases of the throat
and nose, and especially in the admirable work of
Dr. Bosworth, that we need not dwell upon this
branch of the subject. Suffice it to say that Dr.
Bosworth lays stress upon the fact that he con-
siders hay-fever as being due to a vasomotor paresis
of the walls of the blood-vessels lining the nasal
cavity, while the asthma which in many cases, sooner
or later, makes its appearance in the course of the
disease, is a vasomotor paresis of the blood-vessels
of the mucous membrane lining the bronchial tubes.

Treatment. — The treatment of hay-fever may be
most convenientlj' discussed under three separate
heads, namely: (i) Constitutional; (2) local; (3)
treatment of the exacerbation.

I. Leading authorities on the subject of hay-fever
are agreed that the disease occurs in the large
majority of cases in persons of a neurotic tempera-
ment, and that the treatment adopted should be
directed toward building up the tone of the nerrous

July 1 6, 1904]

MEDICAL RECORD.

system, with especial reference to the local nervous
instability, which manifests itself in the nose, as
above mentioned.

(a) One of the best agents for securing a good
tonic effect upon the nervous system is the daily
morning cold plunge, which is to be taken immediately
on rising. The immersion need only last for half a
minute, followed by vigorous rubbing with a coarse
towel. The use of the bath should be commenced
several weeks before the itsual time for the hay-fever
to make its appearance. For those not in robust
health, cold sponging of the neck and chest should be
resorted to.

(6) The mode of life, diet, and exercise should be
regulated.

(c) Patients suffering from hay-fever are verj'
susceptible to taking cold. The}' have a tendency
to perspire easily, and if they allow themselves to
cool ofT too suddenly, or expose themselves to a draft,
they are verj^ apt to bring on a paroxysm of sneezing.
Hence suitable clothing and shoes should be worn.

id) The sleeping-room should be well ventilated.

2. In nearly all cases of hay-fever there is a
pathological condition in the nose, which acts as a
predisposing cause to the development of the disease.
This being the case, a thorough examination should
be made of the nose and nasopharynx of every
patient suffering from hay-fever. If any chronic
inflammatory condition be found, it should be
alleviated ; if any obstructive lesion exist it should be
removed. All sensitive points should be touched
with a caustic, such as a solution of nitrate of silver.

As a rule, hay-fever patients do not come under
observation until the onset of the exacerbation,
which, however, is not a favorable time for the
treatment of the intranasal conditions above men-
tioned. Whenever possible, patients should be
urged to place themselves under treatment in the
spring, or at least, several weeks before the time
when the symptoms of hay-fever usualh" make their
appearance. By relieving any hypersemic, or hyper-
trophic condition, or by removing any nasal ob-
struction, such as polypi, spurs or deflection of the
septum, the severity of the onset of the attack may
be more or less diminished. This plan of treatment
may need to be renewed at the same period for two
or three years, before marked improvement in the
severe cases can be expected.

3. The theory that the uric-acid diathesis should
be considered as a factor in the production of hay-
fever, as taught by such authorities as Haig of
London, Bishop of Chicago, and Wilson of Elizabeth,
X. J., should be given due weight in our considera-
tion of the treatment of the exacerbation. Dr.
Norton L. Wilson {A'ew York Medical Journal,
December 26, 1896) makes a strong plea for the
uric-acid theory in the production of hay-fever. He
recommends the adoption of active measures for the
treatment of the uric-acid diathesis six weeks or two
m.onths before the expected onset of the exacerbation.
He suggests the administration of aromatic sulphuric
acid, or phosphoric acid, for a time, followed bj'
small doses of salicylate of sodium, three grains three
times a day, and cutting off the acid-producing
drinks, such as beer, wine, cider, lemonade, etc.
The following acid-producing foods, especially meat,
should be avoided: all glandular organs, straw-
berries, coffee and tea, meat extracts, vinegar, sour
pickles, preserves, sugar, potatoes, and other starchy
food. Ham and bacon may sometimes be allowed.
The diet should consist principally of cereals, eggs,
fish, fresh fruits, vegetables, milk, and cocoa. Water
should be drunk freely. Dr. Bishop recommends

that the patient should take one or two teaspoonsful
of acid phosphate in a glass of water at bedtime and
on rising in the morning.

According to many observers, notably Dr. Beaman
Douglas, the most satisfactory agent at our disposal,
for internal treatment of hay-fever, is the saccharated
extract of the dried suprarenal gland, while the
active principle of the suprarenal gland is very
efficient in solution in the form of a spra3^ In the
proper doses, the extract of the suprarenal gland,
slows the heart, and increases the force of tBe
systole. It retards the pulse and stimulates the
constriction of the blood-vessels. The blood-pressure
is increased. If a solution of suprarenal extract be
applied to a mucous surface, the capillaries become
markedly contracted, and the tissues become more
or less blanched. Congestion of the nasal mucous
membrane is diminished and the water\' secretion is
rendered less copious and less irritating. The same
is true when the active principle of the gland is used.

Dr. Douglas, in his paper, "The Treatment of Hay-
fever by the Suprarenal Gland" {New York Medical
Journal, May 12, igoo), gives 5 gr. every two
hours, day and night, until giddiness or palpitation
is observed, or until the remedj'' seems to be control-
ling the vasomotor paralysis in the nasal mucous
membrane. Then the dose may be given at longer
intervals, say every three hours, and later every six
hours. The amount may even be diminished to
two doses of 5 gr. each a day, which are to be con-
tinued during the hay-fever season. If disagreeable
symptoms of hay-fever recur, the dosage should be
recommended as already described. He looks upon
it as almost a specific in some cases.

The solution of adrenalin is best used as a spray in
the proportion of 1-5000 in normal salt solution.
The strength may be increased if found necessary.
Prior to its use a spray of some mild alkaline solution
may be used, and after its use it is well to apply a
bland oily spray. It must be borne in mind that the
solution is prone to decompose if exposed to the
light. It is therefore necessary to keep it in a dark
bottle, and it is also well to protect the bottle at-
tached to the atomizer with a piece of dark paper.

I would advocate beginning the use of the supra-
renal extract about two weeks before the time the at-
tack of hay-fever usualty occurs, taking 2 gr. three
times a day with a view to retarding and mitigating
the attack, as far as possible.

The quantity' and irritating quality of the secre-
tic>n of the nasal mucous membrane is diminished
bv (i) treatment of the uric-acid diathesis; (2)
treatment of the intrana-^al pathological conditions;
(3) the use of the suprarenal gland.

Xext to the congestion of the nasal mucous mem-
brane, the most important symptom which presents
itself is bronchial asthma. According to Bosworth,
bronchial asthma occurs, sooner or later, in a large
number of cases of haj'-fever. In his opinion, the
asthma accompanying hay-fever is due to the prin-
cipal predisposing cause of the disease, namely, a
pathological condition in the nose. By directing out-
treatm.ent to these local causes of irritation the
hav-fever and accompanying asthma will be greatly
benefited, and in many instances cured.

As regards the medicinal treatment of cases that
have '.nore or less asthma during the haj-fever sea-
son, the use of the suprarenal gland, both internally
and in the form of spray, will be found of service, by
improving the tone of the nasal and bronchial
mucous membrane. Mention might also be made
of the smoking of stramonium leaves. The dried
stramonium leaves, as found in the shops, when
smoked in a pipe, are kept ignited with considerable

MEDICAL RECORD.

[Jiily i6, 1904

difficulty. A good way to remedy this condition, is
to separate the leaves and soak them thoroughh' in
a saturated solution of nitrate of potassium, then
place them on a dish in the oven until thoroughly
dry. After being thus treated, the stramonium
leaves will burn much more readily, besides obtain-
ing whatever therapeutic advantage there may be
in the use of the nitrate of potassium.

When severe paroxysms of asthma occur, com-
pound spirit of ether is of service.

ror the relief of the bronchitis, which is often very
annoying, the following medicines will be found
useful: hydrastis canadensis, terpine hydrate, and
cubebs. Dr. Saenger of Magdeburg (editorial, New
York Medical Journal, May 15, 1897) recommends
the use of the fluid extract of hydrastis canadensis
in doses of from twenty to thirty drops four times
a day, in chronic bronchitis with an irritating cough.
I have, myself, found this remedy beneficial. Hare
states that terpine hydrate is of value in the bron-
chitis of hay-fever, by increasing the production of
mucus. Cubeb troches are useful and convenient.

One of the drugs which is not much used, but
which will often give temporary relief in hay-fever,
is camphor. It can be administered either by olfac-
tion or internally. It has a tendency to relieve the
congestion and sneezing and to diminish the watery
running of the eyes and nose. Its use has an addi-
tional advantage, in that it has a tendency to quiet
nervous irritability, which is at times a marked
symptom in hay-fever patients. Internally, it can
be given in the form of spirit of camphor, five drops
every fifteen minutes for the first hour, and repeated
at longer intervals as required. It should be given
well diluted in water.

Aside from medicinal treatment, one of the best
methods of obtaining relief from the disagreeable
symptoms of hay-fever, is the cold spinal douche,
for from fifteen to thirty seconds, at a pressure of
from twenty to thirty pounds to the square inch, at
a temperature of 60°. This acts as a powerful tonic
to the central nervous system. It also relieves the
congestion in the nose in a reflex manner, by in-
ducing the contraction of the capillaries in the nasal
mucous membrane. The beneficial effects thus ob-
tained may last for two or three hours, or longer.
Th« cold plunge, shower, or cold sponging may be
used, but the results obtained are not so favorable
nor so lasting. There are few patients who cannot
soon become accustomed to the douche, if properly
administered and followed by a brisk rub. If an
apparatus for giving the douche is not at hand,
water from a pail should be dashed over the patient's
back, the operator standing at a distance.

Another excellent method of obtaining consider-
able relief from the nasal congestion and asthma is
the use of the ice-bag. The ice-bag is to be partially
filled with cracked ice, the pieces being about as
large as a white walnut, and then applied to the back
of the neck and the upper fourth of the spine. The
ice-bag should be kept in this position for ten or
fifteen minutes, and then removed. If the applica-
tion is made as above directed, the relief of the
symptoms characteristic of hay-fever is very marked
and lasts for several hours. It may be used two or
three times a day without untoward symptoms. If
applied at night before retiring, the nasal and
asthmatic .symptoms will be much relieved, so that
the patient will be able to get several hours' quiet
sleep.

A large number of hay-fever patients find a change
of climate beneficial. Most patients are greatly
improved by a sojourn in the mountains, and some
obtain absolute relief. Others find benefit at the sea-

shore, and by bathing in the ocean. The benefit
derived from the surf bathing is not merely due to
the stimulant and astringent effect of the salt water,
but also to the force with which the water enters the
nostrils, acting in a mechanical way, by inducing the
contraction of the capillaries and dilated veins.
The beneficial effect resulting from a bath in the surf
is often marked and lasts for hours. Care must be
taken, however, not to remain in the water too long,
or after the patient begins to feel chilh\ for by so
doing the results sought for will not be obtained to
their highest degree.

The ocular symptoms in ha3'-fever are often very
annoying. There is apt to be more or less conjuncti-
vitis, which may be rendered more intense by strong
sunlight and the irritation of dust. There maj^ be
considerable lacrymation and the secretion may be
very irritating. For this it is well to use Agnew's
eye- water three times a day (boric acid grs. 10,
camphor water, i oz.). I would also recommend
that hay-fever patients wear tinted glasses during
the active period of the exacerbation, as at times
the reflex action of the bright sunlight on the eyes
induces attacks of sneezing, which still further in-
creases the nasal congestion. Thej' also protect the
eyes to some extent from irritating dust.

In the treatment of hay-fever we should avoid the
use of opium in any form. It should be used only as
a last resort, and after all the other means, above
advocated, have been given a fair trial.

I would also recommend that the use of cocaine be
avoided. We should always bear in mind that the
cocaine habit may be formed by its use in a spray.
In a large number of cases it will be found that the
use of the suprarenal gland, both internally and
locally, will give as much relief as was formerly
obtained by the use of cocaine.

Patients should be advised to abstain from the use
of tobacco during the exacerbation of hay-fever. It
has a tendency to produce irritation of the mucous
membrane of the respiratory- tract and to aggravate
any chronic inflammators' condition that may exist.

We should a so advise our patients not to indulge
in alcoholic stimulants.

In giving directions to our hay-fever patients con-
cerning their diet, mode of life, etc., it will be well to
instruct them to avoid walking too fast and getting
overheated, especially if the weather be warm and
damp or foggy, as under these circumstances
asthmatic symptoms are apt to be aggravated.
They should also be cautioned against cooling off too
quickly, or exposing themselves to draughts.

Patients should be advised to avoid driving in the
dust, if discomfort is experienced thereby, such as a
paroxysm of sneezing and increased nasal congestion.
I know of one case, and have been informed of an-
other, in which the smell of the sweat from the horse
when out driving wou d cause great nasal congestion
and discomfort. The first of these patient's could
ride in a trolley car or railway car without dis-
comfort, showing that it was not merely the dust
that set up the irritation.

In concluson. I would say that, if the patient can
be induced to live in a hygienic way as re.gards diet,
baths, ventilation of sleeping room, exercise, etc.,
and will carefully carry out the directions of his
physician, his attack of hay-fever will be consider-
ably mitigated; and his condition will be still
further ameliorated if he can be persuaded to submit
to the necessary rhinological treatment, as pre-
viously outlined. With patience and perseverance
on the part of both phj'sician and patient, it is
certain that considerable and, in some cases, lasting
benefit may be obtained as the result of treatment.

July i6, 1904]

MEDICAL RECORD.

Medical Record:

A Weekly Journal of Medicine and Surgery.

GEORGE F. SHRADY, A.M., M.D., Editor.

THOMAS L. STEDXIAM, A.M., M-D., Associate Editor.

PUBLISHERS

WM. WOOD & CO., 51 , Fifth Avenue.

New York, July 16, 1904.

IMMUNITY AGAINST INFECTION IN ABDOM-
INAL SURGERY.
The prevention of infective disease maj' be effected
in one of two ways, either by offering an obstacle to
the entrance into the organism of the offending
microbe, or by so strengthening the powers of
resistanceof the organism that it isable successfully to
repel the microbic invasion. The same principles
should apply in the domain of operative surgery,
since postoperative wound infection is entirely
analogous in origin to pneumonia or diphtheria, and
in fact we see that they do apply. But in general
surgery the first of the two modes of prevention just
mentioned, that of exclusion of the germs, is so
simple in execution and so certain in result that a
resort to the less simple and less certain preventive
inoculation would be unjustifiable in most cases.
Indeed this method of treatment, which may be
called the Jermerian in distinction from the Listerian,
has hitherto, with few exceptions, been confined to
the prevention of tetanus, unless we may regard the
Pasteurian treatment of threatening rabies as a sur-
gical measure.

There is one extensive field of surgical endeavor,
however, in which the application of antiseptic prin-
ciples, while of course not altogether useless, is
uncertain in its results because of the impossibility
of sealing the wound so as to prevent a subsequent
invasion by pathogenic microorganisms. This field
is the abdomen. Here then is an opportunity to ap-
ply the Jennerian principle in surgery — but how?
Manifestly we cannot immunize against the colon
bacillus by antistreptococcus serum, nor against
Staphylococcus pyogenes by immunization with a
strain of Bacillus coli.and it is even doubtful whether
we could protect against all the strains of the colon
bacillus by a single serum. This being the case, the
problem of the prevention of peritonitis after ab-
dominal operations must be attacked in another way.

One possible solution of the problem was the sub-
ject of a very interesting discussion by Professor von
Mikulicz-Radecki of Breslau in the Cavendish
Lecture which he delivered before the West London
Medico-Chirurgical Society on June 24 {The
Lancet, Jul}' 2, 1904). After rejecting the suggestion
of a specific serum and showing the impossibility of
disinfecting the mucous membrane of the stomach
and intestine preparatory to operation, he said that
the only resort of the surgeon was to increase the
power of resistance of the peritoneum against in-
testinal bacteria by producing an artificial leucocy-
tosis. A number of investigations have shown that,
whether the bacteria are destroyed by active

phagocytosis alone, or whether the leucocytes pro-
duce alexins which kill the bacteria outside the cell
body, or whether those two processes work together,
general leucocytosis certainly does play a very im-
portant part in the struggle against bacteria.

This condition of hyperleucocytosis has been in-
duced artificially by injections (intraperitoneal or
subcutaneous) of alburaose, decinormal saline solu-
tion, bouillon, nucleic acid, and tuberculin. Of these
Mikulicz and his clinical assistant, Miyake of Japan,
obtained the most satisfactory results with nucleic
acid. They found that by subcutaneous injections
of nucleic acid inguinea-pigs, it waspossible to increase
the resistance of the peritoneum to such an extent
that even a considerable quantity of intestinal con-
tents could be placed in the peritoneal cavity with-
out causing damage, but without previous treatment
an acute, rapidly fatal peritonitis followed almost
without exception.

The result of these experiments was so satisfactory
that a practical application of the method was em-
ployed in man . A two-per cent, solution of nucleic acid
was employed and about 50 c.c. was injected beneath
the skin of the chest. In the experiments upon
guinea-pigs the optimum hyperleucocytosis occurred^
about seven hours after the injection (the immedi-
ate effect during the first hour or so was a hypoleuco-
cytosis), but in man this occurs somewhat later, and
Mikulicz has therefore determined upon twelve
hours as the proper interval between injection and
operation. This ensures that the operation will be
performed at the time of the rising tide of leucocy-
tosis.

The proof of a theory lies in its practical working,
and the satisfactory demonstration of this can be
furnished only by a large number of cases in the
hands of many operators. The results of Mikxilicz's
own cases, however, are such as to encourage others
to make a trial of his method. He gave the in-
jections preliminary to forty-five casesof laparotomy,
in which the peritoneum was exposed to infection by
the contents of the stomach, intestine, or bile ducts.
Of the patients operated upon, thirty-eight re-
covered, and of the seven deaths, not one was due to
peritonitis. In most of these cases, in addition to the
injections of nucleic acid, the further precaution was
taken to flush the peritoneal cavity with warm
decinormal saline solution, and it is very possible
that that contributed, in some measure, to the success-
ful outcome, as saline irrigations are known to in-
crease the resisting power of the peritoneum.

THE MEDICAL MAN'S VACATION.
The opinion lateh' expressed by a financier,
noted for personal economy, that vacations
are needless and not beneficial to health,
has aroused a considerable amount of interest in
the matter. Not that the views of the New York
millionaire are considered seriously, but because
the time for taking holidays has come and the sub-
ject is alwajrs worthy of discussion. No one reaUy
thinks that vacations are unnecessary evils, and
that a cessation from work and a change of air and
scene are not for the good of toilers. The majority
of people will continue to take an annual holiday,
and furthermore will derive benefit therefrom to
body and mind. All dwellers in great cities require
a temporary respite from the noise and turmoil of

MEDICAL RECORD.

[July i6, 1904

the crowded streets, and a period of rest or dis
traction from the exciting or monotonous routine of
daily business. There are indeed some who by
reason of their poverty are unable to get away from
the town, but are doomed from year's end to year's
end to exist among wretched surroundings, com-
pelled by an unhappy fate to labor unceasingl}'.
No one, however, who knows the inhabitants of the
tenement districts, will not say that a stay in the
countrj' would do them good. In fact, it may be
laid down as an axiom that to those who live in
modern towns, a vacation is more or less of a neces-
sity. This statement may be made with greater
truth of members of the medical profession than
those of any other class.

The recommendations as to holidays are widely
different. Some advise a long holiday, others a short
holiday two or three times a year. One lays stress
upon the importance of fresh air and a change of
scene, anothei holds the view that sight-seeing
should be strictly eschewed, while yet another will
assert that two or three weeks in bed is the most
sensible manner of spending a vacation. Lastly,
there is the crusty exponent of materialism, who
thinks that the vacation idea is entirely a weariness
to the flesh and a vexation of spirit, a needless ex-
pense for no adequate return, and a grave mistake
in most respects. Quot homines tot sententicB. In such
jeremiads there is undoubtedly a.'substratum of truth,
insomuch as vacations seldom come up to expecta-
tions, and some are total failures. Nevertheless, al-
though perhaps the ideal holiday is seldom or ever
found, it does not alter the fact expressed before,
that a yearly vacation is needed by every worker,
and by no worker more than by the medical man.

The medical profession is, on the whole, the least
holiday-making of all the professions. Not a few
medical men are literally wedded to their profession ;
indeed, sometimes the knot is so tightly tied that
they never sleep away from home, and when in bed
usually have one ear open for the night bell. A
great number of practitioners are perforce slaves
to work and must content themselves with a week's
or, at the longest, two weeks' vacation in the course
of the year. The general practitioner, especially
in the country, has the greatest difficulty in leaving
his practice even for a short time. He and his
patients are on terms of such intimate relationship,
that, if, when the vacation time has come, those
whom he has known for years are grievously sick,
he is unwilling to leave them, and if he does go, de-
parts with almost as great reluctance as he would
leave a member of his own family under like cir-
cumstances.

With regard to the kind of holiday suitable to
the medical man, it would be presumption to advise
as well as an impossible task. Men's tastes differ
as widely as their appearances, while the tastes of
their wives and daughters, who must be consid-
ered, differ even more widely. In a general way,
however, it may be said that the town doctor will
be happier and better "far from the madding
crowd" in the sweet seclusion of a country retreat.
But, although it is well to regard country life
from its picturesque and romantic aspect, the matter-
of-fact side of the question must not be overlooked.
The beauties of rural scenes and of idyllic dwellings
are too often the masks which conceal all kinds of

evils. The moss and ivy-covered cottage in the
woods is frequently but a whited sepulcher. Its
drains are defective, its water impure, and its over-
hanging creepers and surrounding woods and under-
growth are the home of malaria-bearing mosquitos,
and keep the health-giving sunlight from its inmates.
Such points should not be neglected when choosing
a place in which to spend the summer vacation.

The country doctor, upon the theorj', or fact, that
a change of life and scene is the best way to spend
a vacation, should visit the haunts of his busy
fellowmen. Perhaps there is no more healthful
and pleasant mode of taking a holiday for the coun-
try' practitioner than attending the meetings of the
American Medical Association and of State and
County Medical Societies. Such a meeting, for in-
stance, as that which has recently taken place in
Atlantic City afforded unbounded opportunities
for instruction and amusement to the medical
man. At these gatherings he meets and can
listen to men eminent in the profession ; men
from all countries and of world-wide reputation.
Such communion is of inestimable advantage in
many ways; he receives new ideas, and some of the
rust which has gathered upon him in his necessarily
somewhat contracted sphere of life is rubbed off.
Over and above these advantages, the mixing in
the social life of his equals, denied him to a great
extent when at home, tends to enlarge his views.
The unaccustomed stir and bustle of the town or
of the pleasure resort stimulate his faculties, dulled
by the monotonous routine of his daily toil, and
elevate his entire being, so that he goes back to
his work like a giant refreshed. The feminine part
of his family can also participate in the social
amusements which are a part of present-day medi-
cal meetings with equal benefit.

Surgical Treatment of Chronic Nephritis.

In the Scottish Medical and Surgical Journal, for
May, 1904. Dr. Francis D. Boyd reviews the above
subject. The question of surgical interference in
chronic nephritis has been greatl}^ to the front
within recent years, and especially in this country
has gained much ground. Dr. Boj'd says that
Harrison seems to have been the first to advocate
incision of the kidneys in cases in which there
was evidence of increased tension of the organs.
In America Edebohls has been the most prominent
exponent of this mode of surgical procedure — indeed
decapsulation of the kidneys is known as Edebohls'.
operation. Dr. Boyd, referring to the publications
by Edebohls on decapsulation of the kidneys, says:
"As in the cases in which full details are given,
one cannot in several instances accept the diag-
nosis, it leaves one with an uncomfortable and
unconvinced feeling with regard to the accuracy
of the observer's conclusions in the tabulated
cases."

From a physician's standpoint, the author con-
siders that one of the most important contribu-
tions is from the pen of Senator. He denies the
occurrence of one-sided nephritis unless there be
only one kidney. Nephritis results from causes
which are equally applicable to and equally affect
both kidneys. After again referring to and criticis-
ing Edebohls' views. Dr. Boyd concludes as fol-
lows: (i) That while the kidney may undergo
a chronic fibrosis as the result of a local cause, the
occurrence of a one-sided kidney has not been
proved. (2) In chronic diffused nephritis, in

July 1 6, 1904]

MEDICAL RFXORD.

which medical measures have been tried without
benefit, decapsulation of the kidneys may be
justifiable, and may be undertaken in the hope
that relief of tension may facilitate the circu-
lation through the kidneys, may increase urinary
secretion, and may produce decided amelioration.
The operation does not in itself seem to be associ-
ated with such risk as might have been expected.
Many of the recorded cases were in a critical con-
dition when operated upon. The benefit in some
was so immediate and marked that it can only
be accounted for by the relief of tension and im-
proved circulation through the normal channels,
not by the formation of new paths for the circula-
tion. (3) The contention that chronic interstitial
nephritis i»ay be cured by operation has, so far,
not been proved, as the cases on which the claim
is founded are so insufficiently recorded as to
leare the observer in considerable doubt as to the
accuracy of the diagnosis. (4) Surgical measures
in affections purely local and for the most part
unilateral, such as calculus, pyelitis, pyonephrosis,
etc., are eminently successful. In such cases the
fibrosis in the kidney is not a true nephritis, and
may be benefited by operation. (5) In cases of
nephritis, in which cardiovascular changes are
advanced, it is unreasonable to expect anything
but amelioration of symptoms from decapsulation
of the kidneys.

Medical Electricity.

Electricity used in various forins has come to
be a valuable adjunct in medicine and surgery,
and undoubtedly will in the course of time be a
much more important factor in the treatment of
diseases and injuries than it is even now. Medical
electricity is as yet but in its infancy. Of the
many modes of harnessing electricity to the use
of the medical man the production of y-rays is
the most conspicuous, and is fast taking its right-
ful position as an almost indispensable means of
diagnosis in certain cases.

The Hospital of May 28, 1904, contains a resume
of the latest literature concerning medical elec-
tricity. Brock and Stanley Green have pointed
out, in the Quarterly Medical Journal, that the
x-T&y tube is of service in the more complete
definition of diseased lung in phthisis. They have
now had a number of cases to base their de-
ductions upon, and declare that: (i) In no
single case in which the physical signs have
pointed to disease have the rays failed to detect
the mischief; (2) In some cases in which phy-
sical signs have been absent the rays have
shown deposits in the lungs, and in these cases
physical signs have subsequently been detected;
(3) The early diagnosis is certainly helped; (4)
Tkat the extent of the disease is in many cases
shown to be greater than the physician thinks;
(5) That the progress and results of treatment can
be watched with greater accuracy.

Chisholm Williams, in the British Medical Journal,
gives favorable testimony as to the beneficial
effects of high-frequency currents in the treatment
of phthisis. In 1901 he recorded forty-three cases
under treatment, and now of these, three have died
of pneumonia, of tuberculous kidney, and of lar-
daceous disease. He advises that the apparatus
be of the most powerful available. In tubercu-
losis of other parts, joints, etc., the best results
have been obtained by general electrification
combined with a high vacuum electrode used
from the resonator, or the ordinary a;-ray dis-
charge. Cases of old-standing tubercvdous lesions
he states to be very amenable to treatment. In

the treatment of lupus he finds the .T-ray tube as
reliable and to produce as good results as the light
treatment. He urges the use of the high vacuum
electrodes with a vacuum high enough to produce
fluorescence on an ,r-ray screen. Also the patient
should receive on the condensation couch as much
as 350 milliamperes and upward. In opening
the discussion upon the subject of electro-thera-
peutics in the treatment of malignant diseases, at
the annual meeting of the British Society of Electro-
therapeutists, Lewis Jones raised numerous ques-
tions of the first importance which demand solution
ere much advance can be made. Notably is this
the case in the matter of what kind of rays are
of most advantage — whet her the "a:-rays," "cathode
rays," or a combination of the two. He personally
recommends the use of a "medium" tube, and
prefers to operate with the anti-cathode red hot.
He avoids dermatitis by arranging the exposures
suitably, and continues the treatment for three,
four, or five months.

Alan Jamieson, writing in the Lancet, in referring
to the employment of hard or soft tubes in ar-ray
work, states that he has found that weather affects
the rays materially, e.g. on cold, raw days reac-
tions more readily occur. Wild, in the Medical
Chronicle, has grave doubts as to the prophylactic
value of the a;-rays in preventing recurrence after
operation for cancer. A case of splenomedullary
leukemia reported in the Medical Record, August
22, 1903, has been treated by Nicolas Senn with
great success, and other similar cases have been
since reported.

On the whole, notwithstanding the many instances
in which skin diseases, and even malignant diseases
of a superficial nature, have been treated successfully
by this means, it is as a diagnostic agent that the
a:-rays have yielded the most brilliant results. As
remarked before, however, we are only upon the
threshold so far as the use of electricity in medicine
and surgery is concerned.

NrhtH nf tlrr Mttk.

Enforcement of the Law Regarding the Report
of Contagious Diseases. — Dr. Thomas Darlington,
President of the Board of Health of this city, has
addressed a circular to physicians, saying that
the health authorities are very anxious to restrict
the prevalence of infectious diseases, and increase
the accuracy and completeness of the vital sta-
tistics of the city, and that they intend, therefore,
to enforce strictly the provisions of the Sanitary
Code in regard to the reporting of contagious
diseases and births. According to Section 133
of the Sanitary Code, it is the duty of every phy-
sician to report to the Department of Health, in
writing, the full name, age, and address of every per-
son suffering from any one of the infectious diseases
included in the following list, with the name of
the disease, within twenty-four hours of the time
when the case is first seen: Contagious' (very
readily communicable): Measles, rubella (rotheln),
scarlet fever, smallpox, varicella (chicken-pox),
typhus fever, relapsing fever. Communicable:
Diphtheria (croup), typhoid fever, Asiatic cholera,
tuberculosis (of any organ), plague, tetanus,
anthrax, glanders, epidemic cerebrospinal menin-
gitis, leprosy, infectious diseases of the eye (tra-
choma, suppurative conjunctivitis), puerperal sep-
ticjemia, erysipelas, whooping-cough. Indirectly
communicable (through intermediary host) : Yel-
low fever, malarial fever.

The American Medical Association in 1905. —
The date set for the next session of the American

lOO

]\IEDICAL RECORD.

Quly 1 6, 1904

Medical Association is July 11-14. 1905. This
date has been decided on after considerable corre-
spondence. The holiday season for the majority
of medical men is from about the first week in July
to September, and the schools have by that tirne
all closed. Most of those who live in the east will
want to utilize the trip to the association meeting
as their summer vacation, and if the date were that
usually adopted for the association meeting, these
would not be able to attend. In July Portland
has a delightful climate, and consequently there
need be no fear of hot weather. — Journal of the
American Medical Association.

The White League of Pennsylvania has bee'^
chartered for the purpose of providing open-air
treatment for patients suffering from tuberculosis
and unable to provide for themselves. A farm
has been secured in Luzerne County, near Glen
Summit, where a permanent camp will shortly be
built. A temporary camp will soon be opened
at Trout Run, near Bethlehem, with provision
for ten patients. In addition to the camp a hos-
pital is to be built on high ground about ten miles
from Philadelphia.

Cholera is epidemic in Teheran, Persia, the deaths
numbering several hundred daily. One of the
recent victims was a New York merchant who has
resided there several years. Dr. Allen, the American
minister at Seoul, reports that cholera has ap-
peared at An Tung, and that both of the belligerent
armies in Manchuria are in great danger from the
spread of the disease. The health authorities in
Russia fear that the disease may invade their
country from one or both of these sources, and
precautions are being taken to prevent such a
calamity.

Report on Cancer. — The committee of the Cancer
Research Fund made a report at the annual meeting
held in London last week. Some of the assertions
made are rather too dogmatic and positive, as
transmitted by cable, to preserve an altogether
scientific tone, but doubtless the condensation of
the reporter is accountable in part for that. The
committee said that cancer was not caused by a
parasite and was not transmissible from one person
to another. It was denied that cancer was on
the increase, and the effect of civilization on the
incidence of the disease was declared to be nil, since
animMs were sufferers equally with mankind. It
was declared that radium had no therapeutic
influence on malignant growths, but hope was
held out that curative results might be obtained
from a serum which the committee had elaborated.
Newport, Ky., Branch Hospital. — In a decision
handed .down July 8 by Judge Berry in the Circuit
Court, the city of Newport is restrained and en-
joined from locating or maintaining within a mile
of the boundary lines of the Coldspring District
any branch hospital or institution where cases of
contagious disease may be treated. It was thought
that the location of the branch hospital on the
Alexandria pike, about five miles out of Newport,
had proved a solution to a very vexing problem.
Four thousand dollars was paid for the ground and
house, and about $1,000 was expended in fitting
the place up, after numerous other attempts to
locate a branch hospital had proved futile, because
of the hostility of persons residing in the vicinity.
The city will probably take an appeal.

The Association of Surgeons of the Baltimore
and Ohio Railway met in the parlors of the Hamilton
Hotel in St. Louis, June 29, 30, and July i. At
the meeting Dr. H. B. Stout of Parkersburg, W. Va.,
introduced a measure to secure the cooperation

of the surgeons in a general plan to give lectures
and instructions to conductors, engineers, brake-
men, and firemen at all division points regarding
the treatment of injured persons. Officers elected
were as follows: President, H. Slicer Hedges of
Brunswick. Md.; Vice-President, N. R. Eastman of
Belleville, Ohio; Secretary-Treasurer, G. A. Davis
of Summit Point, W. Va.

Joint Meeting of the International Association
of Railway Surgeons and the American Academy
of Railway Surgeons. — A joint meeting of these
two societies was held in Chicago. 111., June i,
2, and 3. The convention met in the Assembly
Hall of Northwestern University. During the
first day the sessions were presided over by Dr.
James H. Ford of Indianapolis, President of the
International Association of Railway Surgeons,
and the sessions of the second and third days by
Dr. S. C. Plummer, President of the American
Academy of Railway Surgeons. An address of
welcome was delivered by Dr. Wm. A. Evans of
Chicago, which was responded to by Dr. George
Ross of Richmond. Va. President Ford discussed
the "Use and Abuse of the Railway Surgeon" in
his presidential address; and President Plummer
selected, as the title of his address, "Following
and Assisting Nature." Many papers were read
and discussed. A resolution was introduced and
adopted vinanimously to the effect that the Inter-
national Association of Railway Surgeons dis-
solve its present organization for the purpose of
organizing the American Association of Railway
Surgeons, provided that a union be made with the
American Academy of Railway Surgeons; and
also that the executive board of the International
Association of Railway Surgeons be authorized
to join with the executive board of the American
Academy of Railway Surgeons and organize the
American Association of Railway Surgeons. The
following are the officers of the new organization,
the American Academy of Railway Surgeons:
President, Dr. John E. Ow^ens, Chicago, 111.; Vice-
Presidents, Dr. R. W. Corwin, Pueblo, Col.;
Dr. G. D. Ladd, Milwavikee, Wis., and Dr. H. C.
Fairbrother, East St. Louis, 111.; Treasurer, Dr.
T. B, Lacey, Council Bluffs, Iowa; Secretary, Dr.
H. B. Jennings, Council Bluffs, Iowa; Editor,
Dr. Louis J. Mitchell, Chicago; Executive Beard:
Drs. D. S. Fairchild, Des Moines, Iowa, and A. I.
Bouffleur, Chicago, three-year term; Drs. S. C.
Plummer, Chicago, and A. L. Wright, Carroll,
Iowa, two-year term; and Drs. W. S. Hoy, Wells-
ton, Ohio, and J. R. Hollowbush, Rock Island,
111., one-year term. There was considerable dis-
cussion relative to the time for holding the next
annual meeting, but this matter was left entirely
to the executive board. It is probable that the
meeting will be held next year some time in the
autumn.

New Jersey State Medical Licentiates. — At the

meeting of the State Board of Medical Examiners
of New Jersey, held at Long Branch, Juh' 5, forty-
three candidates for a State medical license, who
passed the examination at Trenton on June 21-22,.
were licensed. The candidates represented twenty
medical colleges located in Boston, New Haven,
New York City, Brooklyn, Syracuse. Philadelphia,
Baltimore, Washington, Chicago, Toronto, . and
-Naples, Italy. The following attained the Honor
Roll, or a general average of 90 and upward:
Dr. Louise Martha Sturtevant, A.B. of Wellesley,
and M.D. of Boston University- Schr^ol of Medicine,,
attained 91.6; and Dr. Henr>' Augustus Craig, M.D.,
of Columbia University, attained 90.7. The fol-
lowing Officers were elected for the ensuing year:

July 1 6, 1904]

MEDICAL RECORD.

lOI

President, Dr. William H. Shipps, Bordentown;
Secretary, Dr. E. L. B. Godfrey, Camden; Treasurer,
Dr. Charles A. Graves.

Ohio State Board Examinations. — The Ohio State
Board of Medical Registration and Examination
announced on July 5 the result of the recent ex-
amination. Out of 222 candidates 210 were
found to be entitled to a license. Of these, 39
reside in Cincinnati and 30 in Cleveland.

Agitation for a New Milk Law in Chicago. —

Dairy inspection as a means to insure a pure milk
supply for Chicago is not considered strong enough,
as the Chicago Milk Dealers' Association, in a
letter to Health Commissioner Reynolds, attacked
the present system and made a plea for the permit
system. The Health Department Bulletin states
that inspectors will be sent into the country for
the purpose of conferring with and advising the
farmers. During 1900, with one city dairy in-
spector, only eleven farms were inspected. Without
a change in conditions and methods, it is not ex-
pected that four inspectors can report upon more
than forty-four of the 4,000 dairy farms. The
Chicago Milk Dealers' Association believes in
trj'ing a system which has been of untold value in
other cities. It believes that the city should re-
quire that any one who sends milk into Chicago
should secure the privilege and make annual
affidavits that the sanitar}^ conditions prescribed
by the city have been complied with. This plan is
incorporated in a proposed amendment to the
ordinance which provides that in applying for
permits the dairyman furnish information re-
garding the location of the farm, the number,
health, and feed of the cows, the drainage, light,
and ventilation of the stable, methods of handling
the fresh product, and the health of the employes.
The association also advises that the ordinance
require shippers to seal milk cans coming into the
city, to prevent them from being tampered with
while on the way. Instead of fining the receivers of
the unsealed cans, as is the present rule, this new
arrangement would place the punishment where
it belongs, and make the shipper suffer for the
negligence.

International Electrical Corgress of St. Louis. —
An International Electrical Congress will be held
in St. Louis, during the week September 12 to
17. The congress will be divided into two parts,
namely, (i) A chamber of government delegates
appointed by the various governments of the
world, invitations to which were issued at the
beginning of the j'ear from the United States
Government. The transactions of the Chamber
of Delegates will relate to matters affecting inter-
national questions of electrical units, standards,
and the like. (2) The congress at large, divided
into eight sections, one of which is for electro-
therapeutics. The chairman of this section is
Dr. W. J. Morton, New York Cit}-, and the secre-
tary is Mr. W. J. Jenks of New York City. Three
hundred and forty-three official invitations were is-
sued some months ago to well-known workers in elec-
tricity, inviting papers for the congress. One
hundred and sixty-eight of these invitations were
issued to persons residing in countries outside
of North America. As a result of these invita-
tions, 105 American and 59 foreign specially pre-
pared papers are promised to the congress. Of
these, 5 foreign and 15 American papers are in the
section on electrotherapeutics.

The Late Dr. William E. B. Davis.— The Southern
Surgical and Gynecological Association proposes
to honor the memorv of its founder. Dr. W. E. B.

Davis, late of Birmingham, Ala., by erecting a bronze
statue of him. The statue will be unveiled at
the meeting of the association in Birmingham,
December 13 to 15, 1904.

American Academy of Ophthalmology and Oto-
laryngology. — The ninth annual meeting of this
society will be held at Denver, August 24-26, 1904,
under the presidency of Dr. Edward Jackson of
Denver. The secretary is Dr. Derrick T. Vail of
Cincinnati.

The Germantown Hospital, Philadelphia, has, by
the gift of Anna T. Jeanes, come into possession
of a handsome residence on Locust Avenue, near
Chew Street. The income from the rental or
sale will be devoted to the purposes of the hospital.
Ground has been broken for the erection of a
laboratory adjoining the hospital at a cost of
$2,500. This is the gift of Mr. John D. Mcllhinny,
in memory of an infant daughter. The building
will be one-story high and will be used for patho-
logical and bacteriological investigation. A new
building for pay patients, erected at a cost of
$100,000, raised by popular subscription, will be
ready for occupancy in the latter part of July.
It is a three-story fire-proof structure, containing
twenty-five private rooms and a special operating
room.

Home for Nurses at Jewish Hospital. — The con-
tract for the construction of the Nurses Home at
the Jewish Hospital, Cincinnati, has been let.
The building will be three stories in height and
cover a plot of grotmd measuring 35 feet front,
with a depth of 67 feet. It will be built of brick,
with trimmed stone dressing.

A School in Philanthropy. — The success of the
summer school in philanthropic work, which has
been in operation in this city for seven years, has
been so great that a permanent school of that
character is to be established. The first session
will begin early in October under the direction of
Mr. Edward T. Devine.

Dr. Adam Szwajkart has been appointed by
Governor Yates a member of the West Park Board,
to represent the Sixteenth Ward. He is a graduate
of the University of Cracow, and of the Medical
Department of the University of Illinois.

Erection of New Hospital. — Within a few months
the Columbus Hospital at Lake View Avenue and
Deming Place, Chicago, which is under the manage-
ment of the Missionary Sisters of the Sacred Heart,
will be erected, sufficient funds having been al-
ready received to insure the success of the venture.
The hospital will be five stories in height, and will
be equipped with 150 rooms and 20 nurses.

Hamilton County, Ohio, Coroner's Report. —
There were 103 suicides in Hamilton County during
the year ending June 30, according to the annual
report of Coroner Weaver. Of these all were
white, with the exception of two colored women.
It is a matter of record that few negroes commit
suicide. Coroner Weaver also investigated 32
homicides and 358 accidental deaths. His atten-
tion was called to 334 deaths due to natural and
unknown causes. Seven persons died from alco-
holism and the inquests aggregated 834.

A New Journal. — The Missouri State Medical
Association has decided to publish its transactions
in the form of a monthly medical journal and the
initial number of the Journal of the Mtssotiri
State Medical Association appeared on July i.
Dr. C. M. Nicholson is editor, assisted by Drs.
C. Lester Hall, F. J. Lutz, Woodson Moss, M. P.
Overholser, Robert T. Sloan, and L. A. Todd.

I02

:\IEDICAL RECORD.

[July 1 6, 1904

Professor Hofifa of the University of Berlin
delivered a lecture in Germany's section of the
Educational Exhibit at the World's Fair in St.
Louis, on June 25. The subject of the lecture was
Coxa Vera, and it was elaborated by some beautiful
specimens and excellent radiographs. About fifty
leading St. Louis physicians attended the lecture
and a banquet which was given later in honor of
Professor Hoffa.

Dr. Elias Potter Lyon of the department of
physiologj' and dean of the medical department of
the University of Chicago has resigned his position
to become head of the department of physiology
in the medical department of St. Louis Univer-
sity.

Anti-Spitting Ordinance. — Moline, 111., has adopted
an anti-sjiitting ordinance, with penalties varying
from one to five dollars for its violation. Signs
are to be posted to warn the strangers, the care-
less, and the unwary against inadverently spitting
on sidewalks.

Coroner's Fees Inadequate. — The County Officials
of Hamilton County, Ohio, have recently gone back
from the salary system to the old fee system.
This is welcome to most of them, but in the Coroner's
office the salaries amounted to $8,100, while the
annual fees amount only to about $4,100. The
Coroner, Dr. Weaver, is searching the statutes for
relief.

The Chicago Hospital. — The Chicago Hospital
Building Company, a corporation formed to build
the Chicago Hospital at 452 Forty-ninth street,
has given a deed of the property to the Chicago
Hospital for a consideration of $135,000. The
property is located no feet east of Cottage Grove
avenue, and has a frontage of 75 feet and a depth
of 132 feet. The improvement consists of a five-
story brick building. The transfer was made sub-
ject to an incumbrance of $30,000, and the grantee
has given a trust deed to the Merchants' Loan and
Trust Co., to secure an additional loan to John
T. Binkley of $40,000 for five years at 5 per
cent.

A New Sanatorium at Denver. — The Agnes Memo-
rial Sanatorium, for the treatment of pulmonary
tuberculosis, was opened on Julj'' 2, Denver, with
fitting exercises. The sanatorium was built and fur-
nished by Lawrence C. Phipps in memorj' of his
mother, Mrs. Agnes Phipps.

The California Vaccination Law. — The Supreme
Court of California has reaffirmed the constitu-
tionality of the "act to encourage and provide
for a general vaccination in the State." The de-
cision was rendered in a case referred from the
county of San Diego, where the antivaccina-
tionists have been creating no little trouble for the
school board.

St. John's Hospital Made Free.— The board of

managers of St. John's Hospital, in Brooklyn,
which is under the control of the Church Charity
Foundation of the Episcopal Diocese of Long
Island, have decided that after July i, no more
pay patients will be admitted to the institution.
Hereafter the work is to be of a purely benevolent
nature. The number of patients for the present
will be limited to the number of endowed beds.

"The Medical Digest" is the name of a new
journal published in Portland, Me. The editors
are Dr. Ralph Opdyke of New York and Dr. Eugene
D. Chelbis of Portland. The paper is to appear
monthly, the first number being dated April, 1904.
The early issues give promise of a useful and
successful periodical.

OUR LONDON LETTER.

(From Our Special Correspondent.)

BIRTHD.W HONORS FASHION.\BLE BAZ.\AR FOR VICTORIA

children's hospital HARVEIAN ORATION RETURN

CASES OF DIPHTHERIA AND SCARLET FEVER POST-
OPERATIVE VENTRAL HERNIA ST. GEOEGE's HOSPITAL

SLADEN .MEMORIAL OBITUARY.

London, June 24, igo4.
To-DAY the King's birthday is officially celebrated and a
list of honors conferred on the occasion was issued last
night. Among them Mr. C. Holman, the zealou.s treasurer
of Epsom College, and Dr. Thos. Stevenson, Home Office
Analyst, receive knighthoods. In the order of the Bath.
Deputy Surgeon-General Thornton, I. M.S., C.B., and
Surgeon-General Townsend, C.B., become K.C.B. Sur-
geon Ligertwood, formerly surgeon Royal Hospital,
Chelsea, and Surgeon-General Fawcett, Army Medical
Staff, receive the C.B.

The Queen was present for about an hoiu- at the opening
of a grand bazaar at the Albert Hall on Tuesday, in aid
of the Victoria Hospital for Children, and subsequently
sent a letter to the president, congratulating him on the
beautiful appearance of the hall. The sight has been
described as "Fairy land in London," the stalls and
decorations illustrated nursery rhymes and, of course, the
assembly of ladies was most brilliant. On Wednesday
Princess Louise, Duchess of Argyle, opened the second
day's sale. Yesterday the sale concluded and a grand
ball was held in the evening. Over £15,000 was realized,
and after all expenses I hear the hospital will receive about
£11,000.

The Harveian Oration at the Royal College of Physicians
was deUvered on Tuesday, by Dr. Richard Caton of Liver-
pool. He divided his discourse into two parts. The first
dealing with Egj'ptian medicine, in which he gave an
account of some of the results which archaeological research
has arrived at, in reference to the dawn of medical prac-
tice. About 3500 years B. C, the medicine-god, I-em-
Hotep, whose name means "he who cometh in peace, " was
probably a priest of Ra, physician and sun god. From
inscriptions and papyri his temples, where healing
was carried on, were, in fact, hospitals. The later
Greek colonists called them asklepieia. His priests also
practised embalming and so acquired definite anatomical
ideas. In the Ebers papyrus is a passage which the
orator quoted as "wise advice," the importance of which
we have, he suggested, scarcely as yet recognized. It was
to the effect that in heart disease, if possible, the heart
should be made to rest somewhat, and with this I pass by
many interesting remarks to the second subject of Dr.
Caton's able oration. This wa^ devoted to the prevention
of valvular disease. Why do rheumatic joints recover
and the endocardium not? asked Dr. Caton, and replied,
because the joint can rest but the heart cannot intermit
its labors. But it may be made to rest partially, and this
has been his practice for twenty years. He enjoins
absolute quiet, the patient to lie with head at low level,
made as comfortable as possible, encouraged to sleep, no
excitement being permitted, and pain or fever being sub-
dued — in short, he seeks to attain the nearest possible
approach to physiological rest, as enjoined by our Egyp-
tian predecessors thousands of years ago. We may add
iodides to promote absorption of exudations but chiefly
to lower tension, as in aneurysm. Of this plan Dr. Caton
spoke most confidently, after carefully following it for
over twenty years.

Dr. A. Newsholme read a paper at the Medical-Chirurgical
Society on protracted and recrudescent infection in diph-
theria and scarlet fever. Protracted infection in diphtheria
was recognized by Greenhow and Gresswell, but not until
recently has it been observed in scarlet fever. It doubt-
less occurred before the period of isolation hospitals, and
Dr. Newsholme would explain by it the persistent belief
in the infectiousness of late desquamation. He examined
the explanations offered of return cases.which he said were
relatively rare, and did not invalidate the value of isolation
hospitals. These cases were generally connected with
otorrhoea or rhinorrhcea, though in some cases a dormant
infection might be roused into activity by catarrh. Germs
multiplying in the patient himself and collecting on the
rhinorrhoeal lesion with which return cases are generally
admitted would be more numerous than the lesser number
that could obtain ingress from other patients. That in-
creased activity was caused by hospital aggregation was
a mere theory borrowed from that of smallpox. In each
case it is a theory in support of a theory. Relapses of
scarlet fe\-er were compared with those of enteric, and these
are not caused by fresh external infection.

At the Gynecological Society, on the 19th inst., Mr.
Ryall exhibited a giant myoma which had been removed
by Mr. Jessett, although a previous attempt at another

July 1 6, 1904]

MEDICAL RECORD.

103

hospital had been abandoned. Intravenous transfusion
was called for. The patient did well. The tumor
weighed twenty-six pounds. Other cases were mentioned
by those present — one in which the tumor was over
twenty-eight pounds, another twenty-two and one-half
pounds.

At the same meeting, Mr. Stanmore Bishop started a
discussion on the prevention of post-operative ventral
hernia, of which he had had four cases in more than 350
abdominal sections. He urged the necessity of securing
firm union of the peritoneum, fascia and skin, as well as
the combined tendons of the transversalis and oblique
muscles. He discussed also the materials for sutures,
their sterilization and preservation, and showed apparatus
for securing these objects.

Dr. Macnaugh ton -Jones said he usually closed the ab-
dominal wall in the manner shown in Mr. Bishop's dia-
gram, which was practically the plan of Noble of Phila-
delphia, who had lately introduced another method of
suture (diagram exhibited). The speaker closed the peri-
toneum by a fine continuous cumoi suture, dissected the
fascia from the rectus, and united it by continuous suture
passing through the fascia and looping up the muscle at
either side, before penetrating the fascia at the opposite
side, thus closing the wound by complete adaptation or
slight overlapping of the aponeurosis through its entire
extent. Any apparently weak points can then be secured
by interrvipted sutures.

Mr. Charles Ryall said the chief thing was to be sure the
aponeurosis was united throughout the length of the
wound. The union of muscle would not prevent hernia;
that of peritoneum did not add much strength though
important in preventing adhesions. Prolonged rest after
operation was an important preventive.

Dr. J. J. Macau regretted the absence of those who still
used the through-and-through suture. Since the almost
general adoption of suture in layers, subsequent hernia
had been less frequent and less severe.

Professor Taylor (president) had found in the post-
mortem room that union which seemed perfect externally
might be incomplete on the peritoneal surface. For some
eight or nine years he had united the peritoneum with a
continuous suture of the verj' finest silk sterilized by
boiling in a benzine solution. He then passed sutures at
about one-half inch intervals through skin, fascia, and
muscle without including the peritoneum, but before tying
these, he imited the fascia for the whole length of the
wound, with a close continuous suture of the same fine
silk as used for the peritonevmi, over which, if desirable,
a horsehair suture could be tied and passed through the
skin. The interrupted sutures supported the fine ones
and after ten days were withdrawn. The silk ones were
left. He had seen indications of them two months after-
ward. In another case, reopened after a year, they had
completely disappeared. In only three cases had silk
given trouble and they occurred before he used benzine.

Mr. Bishop, in reply, said all agreed that buried sutures
should be absorbable. Neither wire nor catgut were ; the
latter was apt to give way, and if used of the thickness
often tried (No. 8) was almost impossible to sterilize; if
one could rely on catgut being germ-free the difficulty
would be met. By his method it was easy to assure one's
self by both sight and touch that the aponeurosis was
properly united throughout its entire length.

A special court of the governors of St. George's Hospital
was held on Tuesday, to receive the report of the com-
mittee appointed in March, 1903, to consider the desira-
bility of removing the hospital to a more extensive site.
There was a large attendance, and Lord Windsor presided.
The majority of the committee were against removal but
there was a minority report. In accordance with the
majority, a resolution was moved "that it is not desirable
at the present time and under existing circumstances to
remove St. George's Hospital from its present site." It
was urged that this site was one of the best in the world.
On the other hand, it was argued that the hospital is spend-
ing at the rate of ;£io,ooo beyond its regular income and
a sale of the site would .cover that. The resolution was
carried. A resolution that the present is not a favorable
time to appeal for funds for rebuilding was defeated. Resolu-
tions were carried for utilizing the new site lately acquired
for the immediate requirements of the hospital, and au-
thorizing negotiations for the acqtiirement of additional
leaseholds. Just before the close of the meeting a letter
was read from Dr. Rob Barnes offering ;£i,ooo toward the
expenses of the medical school.

Mrs. Percy Sladen, to perpetuate the memory of her
late husband, Mr. Walter Percy Sladen, at one time \ ice-
president of the Linnean Society, has undertaken to devote
the sum of +^20,000 to the promotion of research or inves-
vestigations in natural science, more especialh' in zoology,
geolog}', and anthropology. Mrs. Sladen has appointed
the first trustees of the Percy Sladen Memorial Fund —
four in number.

^ Edward Trimmer is a name appended to thousands of
diplomas of the Royal College of Surgeons during the
forty-two years he served that corporation as secretary.
He retired in igoi. After some months' suffering from
malignant disease he has just passed away in his seventy-
eighth year.

Sir David P. Ross, late Surgeon-General of British
Guiana was M.D., Edinburgh, 1863, and M.R.C.S.,
England, 1864. The same year he entered the army
service. Was for twelve or thirteen years in various
medical posts in Jamaica; and his subsequent career in the
colonial service has been distinguished. In all his varied
positions, from a student onward, he was esteemed by
hosts of friends and colleagues.

The death of Mr. A. O. Mackellar, F.R.C.S., Chief Sur-
geon of the Metropolitan police force and formerly surgeon
to St. Thomas' Hospital, occurred on the 15th inst., at the
age of fifty-eight. He was M.D. and M.Ch. of the Royal
University, Ireland, i86g. He went out to serve "as
surgeon on the ambulances sent to help in the Franco-
Prussian. Turko-Servian, and Russo-Turkish wars, was
made Knight of the Military Order of Merit of Bavaria,
of the Gold Cross of Takovo, and of the order of the
Medjivich.

OUR PARIS LETTER.

(From Our Special Correspondent.)

SERPENT VENOM MILLIAMPfeREMETER FOR X-RAYS

BREAST-FEEDING FOR THE CHILDREN OF FACTORY

WORKERS X-RAYS IN CANCER SOCIAL ASPECTS OF

MEDICAL CHARITY POISONING BY CAMPHOR NAPHTHOL

DEATH OF PROFESSOR MAREY.

Paris. June 10, 1904.
At the Acad6mie des Sciences, Calmette recently pre-
sented the result of his investigations concerning serpent
venoms and their antagonistic serums. He differentiated
two distinct substances in these venoms, one acting on
the blood, the other on the nervous centers. The anti-
toxic activity of an antivenomous serum is easily deter-
mined by experiments in vitro, in which varying amounts
of antitoxic serum 'are made to act on a constant quantity
of the defibrinated blood of the horse or of the rat, con-
taining a constant amount of venom. D'Arsonval pre-
sented a milliamp6remeter intended to measure the in-
tensity of a current circulating in an x-Ta.y tube. This
method will make it possible to record, rapidly and
practically, the strength of the Rontgen rays emitted by
a tube.

At the Academie de M6decine,in the session on May 24,
Professor Budin made an interesting report on the neces-
sity of breast-feeding for the children of workers in mills
and factories. The Academy afterward indorsed this
report and forwarded it to the Minister of the Interior.
The figures show that among children who die under one
year of age nearly half are overcome by diseases of the
digestive tract. The great cause of these diseases is
artificial feeding; therefore nursing ought to be made
possible. The labor organizations should be prevailed
upon to permit women to nurse their children. Professor
Budin calls to mind the fact that the Italian Parliament
enacted a law in 1902 that in all factories occupied by as
many as fifty workers there should be a room for nursing.
The Academy should, the speaker urged, express the
opinion that in all industries and establishments mothers
ought to be authorized to absent themselves regularly to
nurse their children, and that creches and special rooms
should be established near the places for work, where the
children could be cared for and nursed.

At the meeting of the Societe des Internes et Anciens
Internes des Hopitaux de Paris, held May 26, Dr. Leredde
showed two patients with epithelioma of the face, who
had been subjected to the action of the Rontgen rays
during only five or si.x exposures of from thirty to forty
minutes each. The photographs of these patients, taken
before the treatment, showed considerable epitheliomatous
masses, situated in one case on the left cheek, in the other
on the forehead. The presentation of the patients them-
selves gave the opportunity of noting the disappearance
of the neoplastic masses. Following this presentation, an
interesting discussion arose in regard to the action of
.%-rays on epitheliomata. Cancerous tumors in active pro-
liferation, malignant epitheliomata, seem clearly to be
influenced, retarded in growth, and even destroyed by the
Rontgen rays. The hard, homy tumors, on the other hand,
show no well-marked effect. As to the influence of the
Rontgen rays on internal cancerous tumors, this appears
to be rather adverse than otherwise. Indeed, Dr. Jacquet
cited a case in which the a;-rays evidently hastened the
death of a patient suffering with inoperable carcinoma of
the stomach. Dr. Pechon also cited a case of non-ulcer-
ating sarcoma of the thigh, treated by exposure to x-rays,
which was followed by general sarcomatosis and the death
of the patient.

Mesureur, director-general of the "Assistance Publique,"
delivered a remarkable address, at the same meeting, on

I04

MEDICAL RECORD.

Qvily 1 6, 1904

the social r61e of the "Assistance Publique." He showed
how, since the adoption of the altruistic ideas advanced
by the French Revolution, the dignity of the indigent
patient has been actually safeguarded, and how he has
not been considered, as formerly, a dangerous element,
and one prejudicial to society. Since the alleviation of
misery devolves upon the "Assistance Publique" it ought
preeminently to consider its prevention by means of
social laws. ' Laws for the protection of the woman and
the child give, from this point of view, an immediate and
certain return, for in safeguarding their health and their
capability for work, both the woman who is to be the
mother and the child who is to be the citizen and the
soldier of the future are protected.

A great project, the most important, perhaps, which
would considerably lessen the debt of the "Assistance
Publique," is that which relates to the relief of the aged
and incapacitated workers, and to the provision of homes
for the superannuated. Thus Society, diminishing little
by little the causes of misery, establishing the right of the
individual to the consideration of humanity, will finally
cancel its debt to humanity. And yet. no laws can wholly
do away with misery and illness, for there will always
remain some who are starving and some who are ill. The
"Assistance Publique" is indeed at hand, as an automatic
instrument, to distribute succor, to relieve the hunger of
a day. but never, by itself, will it raise up again a being
who has fallen. To its official efforts must be added the
disinterested help of private individuals who will give that
useful counsel, that moral support, which will reawaken
dormant energy, will arouse the power for work, and
will give assurance for the future.

It is in the hospital that the divers forces of this charity
can unite. The patients, in efiEect, in coming to the hos-
pital, largely pay their social debt by constituting the
vast field where science reaps its harvests, where all the
youths of our scientific schools find the essential material
for their studies. Passive and apathetic, the patients
contribute their part to the progress which has made the
renown of the French medical schoo so wide spread.
The "Assistance Publique" considers that its honor lies
not only in the fact that its hospitals afford an asylum for
those who suffer, but also in the fact that they constitute
a great practical school in which the country may take
pride. It demands that the physician love these who so
generously offer theii; sufferings as a means of instruction,
love them in order to cure them, and also that he recognize
in the patient a human being whom a word can console.
It demands that these guardians of science, these intellec-
tual giants, who have dedicated their great powers to the
cause of healing, shall endeavor, by arousing a greater
sympathy among men, to create a better society, with less
of suffering and more of justice.

At the Society of Surgery, the question of intermittent
hydronephrosis, of which we spoke in our last letter to the
Medical Record, was again discussed. Dr. Guinard
then reported a case of poisoning by camphor-naphthol,
in which a man succumbed a few minutes after its injec-
tion into the cavity of an abscess from which the pus had
just been evacuated. Kirmisson also cited cases in which
camphor-naphthol injections had produced untoward
accidents. The symptoms always take the same form,
that is, either syncope or epileptiform attacks. Guinard
stated as conclusion of his communication and of the dis-
cussion which followed, that it seemed to him tlie admin-
istration of camphor-naphthol by this method should be
discontinued.

Among the serious losses which the scientific world has
recently experienced we would mention the death of Profes-
sor Marey, member of the Academy of Medicine and of
the Acad-cmy of Sciences, whose works on experimental
physiology are well known. The sphygmograph and the
cardiograph of Marey are instruments too \\'idely distrib-
uted, too generally adopted throughout the worfd, and of
a usage too common, for it to be necessary to lay stress on
the great discoveries of this savant. During more than
forty years, indeed, Marey devoted himself to the difficult
problems of the heart and the blood-vessels. His great
work was the development of the graphic method, that is
to say, the direct inscription through the medium of pens
of the biological phenomena observed. By a series of
photographs Marey was able to study and to recognize all
the phases of the circulation of the blood in men and in
animals. Moreover, he made an interesting and valuable
study of the flight of birds and of the various movements
of their wings.

Health Board Changes. — Commissioner Darlington has
again shifted the assistant sanitary inspectors. Dr. Moore,
who was sent from Queens to Richmond, two weeks ago.
goes back to Queens; Dr. Sprague. who was sent from
Richmond to the Bronx, comes to^Manhattan ; Dr. Murray,
who went from Brooklyn to Queens, goes to Richmond.
Dr. Pursall, who went from Manhattan to Brooklyn, will
remain there one week longer.

OUR BERLIN LETTER.

(From Our Special Correspondent.)

QUINQUAUD'S disease BERLIN LIFE-SAVING SOCIETY

ECLAMPSIA AND THE NERVOUS SYSTEM INFANT

MORTALITY FIRST REPORT OF MEDICAL SCHOOL IN-
SPECTORS.

Bbrliv, June 4, 1904.
.^T the meeting of the Society for General Medicine, held
May 16, Furbringe delivered an address concerning the
value of Quinquaud's sign. The inquiries of many physi-
cians had caused the speaker to give closer attention
than before to the nature of this sign. Speaking of its
history, he told how a teacher by the name of|Quinquaud, as-
Maridon made known in igoo, made the following ex-
periment with his scholars in 1893: He had them place
the finger tips of a patient against the palm of his hand,
and held them there a few minutes. Among the students-
several were evidently scornful. In a little while crepi-
tation was apparent in the phalangeal joints of the
fingers that had been placed in position. This phenom-
enon can be observed only in the case of drinkers,
and then not with moderate drinkers. The degree,
therefore, to which alcohol has been misused can be judged
by the strength of the crepitation. Furbringe examined
in this way five hundred patients, drawing them from,
both the hospital and his own private practice. He
divided those whom he examined into four groups:
almost total abstainers, moderate drinkers, drinkers,
and drunkards. He divided the sounds observed into
three groups; perceptible, moderate, and strong. In
the case of the drinkers, he found it sufficient if they placed
two fingers only in position, the two chosen being the
ring and the middle finger. He prepared the following
table :

Moderate Drinkers Drunkards

Absent, 89.5 per cent. 10.5 per cent.

Moderate, 72 per cent. 2S per cent.

Strong, 41.5 per cent. 58.5 per cent.

In brief, it may be said that in the case of the moderate
use of alcohol, this phenomenon occurred only to a slight
degree, and that where it was more marked, the case
was that of a drunkard. In comparing tremor with
this sign, Fiirbringe made the following table:

Absent,

Moderate

Strong.

Moderate Drinkers
9i per cent.
73 per cent.
22 per cent.

Drunkards

7 per cent.
27 per cent.
78 per cent.

It is evident from these tables that one can recognize a
drunkard with greater certainty by tremor than by
Quinquaud's sign. It is to be noticed that neurasthenia
and hysteria influence both these phenomena. In no
case was there any change in the joints. The phenome-
non ceases when the subject is tired, but reappears after
a short time. Furbringe drew the conclusion that
Quinquaud's sign should not be taken alone in making
the diagnosis of alcoholism, but it is of value in con-
nection with other symptoms.

The recently published report for 1903 of the Berlin
Life-saving Society gives the opportunity for a few gen-
eral remarks concerning the present situation and the
outlook. In the ca.se of street accident or sudden illness
in a house, the sufferer heretofore would receive help
first from the stations established by the Red Cross So-
ciety. There are twenty of these stations in Berlin,
with their directors and assistant physicians, who, it is
said, know how to make a very good practice for them-
selves from the patients who come to the station, and
have made inroads upon the practice of the physicians
of the district. In spite of this, the number of stations
established was not increased according to the demand.
Seven years ago the Berlin Life-saving Society was
founded by Morris von Bergmann, and this society at the
present day has fifteen head stations, chiefly in the cities
and in connection with the royal hospital, and also ten
relief stations. In the latter, each physician of the dis-
trict is on duty from two to four hours every week.
Care is taken that one in laying claim to the help of a
station does it but once in the cour.se of an illness. The
Life-saving Society is doing a very great work through
the introduction of a central station for the care and
attendance of the sick of Berlin, concerning the great
social and humanitarian significance of which movement
we shall speak later. According to the yearly report,
6,074 cases were treated in the chief stations, and 10,946
in the relief stations. The increase since last year has
been remarkable. A year ago union with the accident
stations was refused by the Life-saving Society, but on
April 19. 1903, a common agreement for first aid was es-
tablished.

An interesting discussion took place at the meeting of
the Obstetrical and Gynecological Society. It had to
do with the still unsolved problem of the cause of eclamp-
sia. Bruno Wolf had repeated the well-known experi-
ments of Blumenreich on animals, in which he removed

July 1 6, 1904]

MEDICAL RECORD.

loS

both kidneys from a large number of rabbits, sorne being
pregnant, and some not. He made the following im-
portant deductions: (i) In the case of a pregnant
animal, both of whose kidneys have been removed, the
foetus dies before the appearance of any ursemic syrnp-
toms in the mother. (2) Typical uremic attacks, with
convulsions, occur very seldom after the operation—
twice out of seventy-four cases. Blumenreich believed
that Wolf had overlooked the convulsions because they
affect, for the most part, chiefly the neck rnuscles. 01s-
hausen reported a case in which he, in spite of cutting
off the action of the kidneys known to be failing had
seen no convulsions. For this reason it was plain that
the poison of eclampsia is something different from the
uraemic poison due to extirpation of the kidneys. Mach-
enrodt had seen a similar case, and Olshausen instanced
the fact that in the end stages of carcinoma which causes
suppression, uraemia has been observed, but not convul-
sions.

For the past week there has been summer weather in
Berlin, and already the waiting rooms of physicians, es-
pecially of those in the working districts, are full of
■children. The mortality among infants has increased
greatly. At the beginning of last month, much light was
thrown on this question at a meeting of the newly-formed
society for combating the death rate of infants. Pro-
fessorHubner held, in this discussion, that, as a result of
the falling off of nursing in Berlin in 1898, the mortality
of infants had increased — and that solely because of a
lack of patience and will power on the part of the mothers.
While out of i.ooo living of the general population 18
die. out of I.ooo living infants 2S6 die. Since in the
Strahlauer Fovmdling Asylum out of 1,000 children
only 40 die, an effort to diminish the death rate of children
seems wise. As a return to breast-feeding will take some
time, the thing to do now is to improve the cow's milk.
Ostertag briefly stated the question from the patho-
logical point of view. The milk from diseased cows is
capable of transmitting typhoid fever and tubercu-
losis, and may become poisonous from diseased udders,
and also from medicines or food poisons contained in
the milk. The milk of healthy cows may be poisonous
when the milking is not done in a sanitary manner, or
when the milk is not kept cool, for the bacilli which
cause milk to sour are not killed by heat. Concerning,
the regulation of the milk supply, Engel made the state-
ment that in Berlin over 2,000 children were injured
by cheap miUc. Through the action of the society many
dairy companies have agreed to have their cows, stalls,
etc., inspected by veterinarians and physicians. The
director of railroads has been asked to have refrigerator
cars for transporting the milk. Further action of the
society has brought about the following; (i) Copies of
regulations will be sent to dairies, physicians, infants'
and children's asylums. (2) Midwives will be instructed
in regard to the value of breast-feeding. (3) Notices
from the society w^ll be sent weekly to the mothers of
the new-bom, with a list of the inspected dairies, and with
instructions regarding the care of milk and the feeding
of infants. (4) .\ relief fund is to be established: (a) for
poor mothers, so that by better nourishment for them,
better nourishment may be assured for the children ; (6)
in order that poor people may be able to buy better
cow's milk ; (c) for providing for the destruction of the
milk of diseased cow-s, after imposing a fine upon the
dairv. (5) An agreement is to be entered into with other
societies pursuing similar courses, and as manj- cooper-
tors as possible won in distant places.

How necessary the improvement in the nourishment
of children is, was shown by a recent report concerning
the work of the Berlin school physicians, appointed in
the spring of the present year. Ffteen thousand children,
recently entered in school, were examined by thirty-six phy-
sicians. Ten per cent, of all the children were foimd to
be physically or mentally i.mfit, and excused from school
attendance for from one-half to one year. Of these, 25
per cent, suffered from general physical debility, 16 per
cent, had not overcome the results of the sicknesses of
childhood, 5 per cent, had tuberculosis, 15 per cent, suf-
fered from anaemia, scrofttla, or rachitis, 10 per cent,
■were undeveloped mentally.

A GARDEN PARTY GIVEX BY DR. LORENZ
TO AMERICAN STUDENTS IN VIENNA.

(From an Occasional Correspondent of the Medical Record.)
Two weeks ago the Anglo-American Medical Association
of Vienna — composed chiefly of American physicians who
are studying in the various clinics in this Mecca of medical
pilgrims — invited Prof. Dr. Adolph Lorenz to dine at the
association headquarters and after the dinner give a lecture
upon any subject he should elect. Dr. Lorenz accepted
the invitation, and gave a lecture on Coxitis and his
method of treatment. Following the lecture he spoke at

length of his reception in America by the profession, and
of the warm hospitality tendered him wherever he went
while there. He next spoke of his — heretofore — inability
to return any of that hospitality, and he took this oppor-
tunity of extending to the members of the association an
invitation to come to his summer home, overlooking the
beautiful blue Danube, and attend a garden party, the
association being privileged to set the date which would
best conform to their convenience. The association
acted at once upon the invitation and voted then and
there to accept the generosity of Dr. Lorenz, and Friday,
June 24, was set as the date.

The weather was perfect, cool and pleasant, an ideal
June day, the members of the association and their wives
met at Alserstrasse station in time for the afternoon
train which was to take them to Greifenstein-Altenberg,
Dr. Lorenz having insisted upon bearing every expense of
the trip for each of his guests. We reached Attenberg
about 5 130, and were met at the railway^ station by the
genial doctor, who greeted every one individually in the
most gracious manner, then piloted us up a woody moun-
tain road in the dehcious coolness and fragrance of the
shade and odors of the flowers and shrubs, to an opening
commanding a most extensive view of the Danube and
its valley for many miles, and of the most glorious country
imaginable, mountains in every direction, many of them
surrounded by picturesque old castles, and everjTvhere
winding in and out, "like a blue ribbon," the lovely
Danube. .

The rare beauty of the scene cannot be expressed in
mere words. It burst upon our view so unexpectedly
that we were spell-bound for several moments. Soon,
however, our spell was broken, for as we moved on a
little further we were greeted in the warmest and heartiest
manner by Madam Lorenz, wife of our noted host, who
with her sisters had arranged a booth, under a huge
umbrella floating from the top of which were seen
the stars and stripes of our own loved country together
with the orange and black of Austria, Music was also
there, furnished by a company of Vienna musicians.
We were invited to seat ourselves upon the grass to
rest and enjoy the beauties around us, while we were
served with tea, coffee, seltzer and white wine, beer, cake,
and cherries. And jkWi cherries! One could not find in any
land more perfect fruit and more varieties. When we
had enjoyed this pleasant refreshing for a time we were
invited to continue our walk a little further, through
lovely acres of currants, gooseberries and cherries, ori
dowii to the beautiful villa of Dr, Lorenz. which nestled
about half-wav down the mountain. Dr. Lorenz seemed
to be everywhere, first in the fore-front, then in the rear
and all along the line, and 'twas a long line, as we marched
in "geese-walk" as the doctor expressed it (Ganse Marsch)
about eighty of us — to his home.

It would "be impossible to imagine a more cordial wel-
come than was accorded us, as time and again our de-
hghtful host urged us to "be at home, " "be at home.

The villa consists of an original or old part and a very
handsome new part. The stones of this new part have
come entirely from old and noted Vienna buildings which
for one reason or another have had to be taken down, and
Dr. Lorenz bought them and had them transferred to
his country seat, and when sufficient had been collected
in this way he had the beautiful new part of his dwelling
put up. the balustrade surrounding the wall and grounds
came from an old stone bridge which crossed the Danube
near Vienna at one time.

The ladies were taken into the private rooms ot ttie
house to remove their wraps, smooth out the wrinkles
and shake off a little of the railway dust, then went out
to assemble in the palatial hall, while the doctor '«'ith the
professional men ascended the stairs. The guests find-
ing places in the beautiful gallery overiookmg the hall,
Dr Lorenz stepped forward into a little balcony and
addressed his guests in the warmest words of greeting
and welcome. He welcomed the wives of the physicians,
whom he considered as representing that type of Arnencan
woman, who, as doctors' wives, shared the hardships ot
a doctor's Hfe. He "welcomed the two lady doctors, whoin
he considered as that type of American woman who stood
for woman's emancipation, and he welcomed the lady
who as neither doctor nor doctor's wife, was known the
worid over, and who had done so much for the profession

Mrs, Armour — who had come out to join the Americans

in their pleasant treat at his home.

He spoke again of his appreciation of all the American
hospitality which he had received, and said that it gave
him great pleasure to welcome us as his guests. Dr. t. L.
S«-ift, of the United States Army, responded to the word
of welcome in a very pleasing manner. After this Ur.
Lorenz escorted us through his house, showing us the
various apartments, the beautiful paintings from the
brushes of the old masters; pointing out to us, here and
there some object of special interest. We were even

io6

MEDICAL RECORD.

[July i6. igo4

invited to inspect the kitchens, which were truly works
of art, with their spotless tiled floors and wainscoting.
Everything of the most approved hygienic make up,
which, to quote Dr. Lorenz, "were of American- Viennese
manufacture."

The house is truly beautiful. From every window one
found the most glonous views of the surrounding country,
while within the arrangement of the house, its furnishings
and hangings, proclaimed the exquisite taste and appre-
ciation of the harmony of color of the host and hostess.

The sixteen-months old son of Dr. Lorenz claimed (Con-
siderable attention — a beautiful blue-e5'ed boy, strongly
resembling his noted father, the perfect picture of health
and happy disposition.

We were now ushered out to enjoy the beautiful grounds
surrounding the house, and a little later escorted to the
tennis court, which was most perfect if its kind. Here
we found many tables spread with snowy linen and shin-
ing silver and flowers in profusion arranged about each
place in a most artistic manner. Overhead were strung
dozens of very pretty Japanese lanterns. At one side of
the court was the dais upon which were seated the Viennese
musicians who made music for us during the afternoon.
They played and sang many very pretty selections during
our meal. The supper was ser\'ed in the most attractive,
dainty manner, and consisted of the most tempting, de-
licious food one could wish for. Here again our interest-
ing host and his good Frau flitted here, there, everywhere,
among their guests, looking after each one's comfort and
appetite in a manner delightful to see. Nothing was
left undone that could in any way add to the pleasure
and content of each and every guest. After the meal the
musicians played America, whereupon we all arose and
sang the national hymn right lustily. This was followed
by the "Wacht am Rhein" and the Austrian national
hymn. Professor Lorenz at this juncture presented each
guest with a souvenir post-carte upon which was a picture
of his villa, and for those who desired it, both he and his
wife added their signatures.

The tables were pushed to one side and the musicians
began to play dance music in such an inviting manner
that the toes of the younger members of the profession
could not resist, and soon the scene changed to one of
frolic and fun, which lasted until about ten o'clock, when
the doctor's carriages drove up prepared to take the
ladies to the railway station, a short distance away, and
the delightful "garden party" disbanded.

The event was certainly one in a lifetime, an afternoon
and evening never to be forgotten by those of America's
medical profession who were privileged to enjoy it.

The following physicians were present : W. M. Engpl-
bach. G. A Gardener, F. G. Harris. J L. Jacques, O. H.
Kraft. W. H. Lambom, G P. Marquis, F. R. Morton, Brown
Pusey, G W. Parker, H. Schafer, and J. I Wemham, of
Ilhnois; A. E Austin, D W. Clark, F. J Hurley, D. J. Mc-
Sweeney, A E. St. Clair, of Massachusetts; .H L. Aller,
F. Goldfrank, Mary Sutton Macv. Isabelle Thompson
Smart, A. W. Booth, of \ew York; E. S. Geist, D. N. Lan-
do, H L. Williams, of Minnesota; Francis W. Alter H. W.
Ely, H. H. Wiggers, Tubman, of Ohio; H. L. Akin, E C.
Henry, S. J. Jones, of Nebraska; A. L. Mackenzie, E A.
Mallon, H. G. Wertheimer, of Pennsvlvania; E. D. Clark,
F. N. Hibben, of Indiana; Louis Ras.sicur, F. L. Stuver,
of Missouri; E D. Chipman, Chas. Fitzgerald, of Connec-
ticut; E. F Dodds. L. H. Fligman, of Montana; H. J.
Schlageter, A. S. J. Smith, of California; J. J. Sullivan,
•New Jersey; E Van Hood, Florida; S. K. Simon, Louisi-
ana; C. E. Zerfing, South Dakota; Bernard J. O'Conner,
Kentucky; A. C. Behle. Utah; R. P. Daniells. Wisconsin;
R. H. Dean, Iowa; J. H. Davis, Colorado; A. W. Ives,
Michigan; C. A. Lilly. Kansas; Walter Luttrell, District
of Columbia; E. L Swift, United States ArmvA. H.
Bennett, Adelaide, Australia; W. H. Gooddcn.' Bristol,
England; A. S. Wilson, Aberdeen, Scotland.

PHTHISIOPHOBIA.

To THE Editor op the Medic.\l' Record:
Sir: I have only lately read the very able plea for
"Justice to the Consumptive" made by Dr. S. A. Knopf
m your issue of January 2. In quoting me as opposed
to the Goodsell-Bedcll law, I am sorry to confess that
Dr. Knopf does me too much credit. 'Mv opposition to
this bill was solely on accoimt of .some details that seemed
to nie to make its operation impracticable. I am the
rankest kind of a phthisiophobe, though no longer of
an age or build to have any personal fear of the disease.
Statistics show that, excluding deaths from violence
and old ago, tuberculosis kills about a quarter of us all,
hence us control has just about one-third of the impor-
^^P1 °^ ^" other diseases together. A parasitic disease
which has no necessary intermediate host, which re-
quires no peculiar method of implantation, and which
IS not scmelmcident.can. according to our present knowl-

edge, be controlled satisfactorily only by the general
principles of quarantine.

It is straining at a gnat and swallowing a camel to
subject patients with acute exanthematous diseases —
which are all semelincident — to the hardships of quaran-
tine and to allow tuberculosis patients, in the stage of
discharge, to go free. I believe that whatever diminu-
tion in the prevalence of tuberculosis has thus far oc-
curred, has been due mainly to professional and lay
phthisiophobia, and not to any considerable degree to^
condemnation of cattle, improvement of resisting powers,
or therapeutic measures against the existing disease.
I believe, also, that just as leprosy was removed from
most European coim tries in the middle ages by enforced
segregation, so enforced go\emmental segregation in
sanatoria is the only promising method of dealing w4th
the modem problem of tuberculosis.

With regard to the exclusion of tuberculous immi-
grants, I agree with the Surgeon-General of the U. S.
Public Health and Marine Hospital Service that no
immigrant should be admitted who is anj' way a menace
to our own country. Indeed, I would go much further,
and admit only a verj' superior class of prospective
citizens. In other words, when the matter concerns the
general welfare of my countrj'men, I w^ould be absolutely
cold-blooded and selfish.

A. L. Benedict, M D.

156 West Chippewa Street, Bufpalo. N. Y.

INFECTIOUS DISEASES IN PERU.

(From Our Special Correspondent.)

Arequipa, May 31, 1904-
The bubonic plague seems to have taken a permanent
hold of Lima and Antofagasta. It is probable that from
these centers it will extend to the rest of the coast. In
Lima the cases are not numerous and are of a compara-
tively mild character, many of those attacked recover-
ing and the infectivity being low.

Hero we are having smallpox and a few cases of diph-
theria. The former, when treated early by touching the
papules with carbolic acid and also giving the same remedy
or salol internally, generally doing well and leaving little
disfigurement.

Diphtheria, if treated early by antitoxin and a mixture
of tincture of chlorate of iron, solution of ammonium
acetate and potassium chlorate taken in lemonade, and
the throat swabbed out with peroxide of hydrogen and
glycerin, is not very fatal. The infection of diphtheria,
may last for a long time.

1 saw in consultation this month a boy of eight years,
suffering from diphtheria. More than two and a half
years previously I had seen his aimt with diphtheria in
the same house. There was no other known or suspected
source of infection. The house had been shut up after
the illness of the aunt.

The Boston Medical and Surgical Journal, July 7, 1904.
Aciduria f(Acetonuria) Associated with Death after
Anaesthesia. — E. G. Brackett, T. S. Stone, and H. C.
Low report a number of cases which present certain feat-
ures in common : Vomiting associated with collapse ;
a very weak and rapid pulse; an absence of fever until
just before death; cyanosis in the fatal cases causing
extreme dyspnoea; apathy and stupor alternating with
periods of restlessness at first, but in the fatal cases grad-
ually deepening into coma and death; and the presence
of acetona in the lireath and urine. In six cases the symp-
toms came on without operation. In three of these
cases the symptoms came on the day after entrance, and
in one two daj's after. In one case the symptoms came
on after the child had been in the ward for four weeks
and was up and about. In seven cases the symptoms
followed operation. Three of these patients died, four
recovered. In the four milder cases the symptoms came
on between 12 and 24 hours afterward. In the three
fatal cases, alarming sj-mptoms came on after about 12
hours, but in none of the cases was the recovery from
the operation quite normal. Those children in whom the
symptoms were severe were of high-strung, nervous tem-
perament. The symptoms coming on after operation
were usually more severe than those coming on without
operation, although there was one rapidly fatal case in
the latter group. Death in the fatal cases occurred from
12 to 36 hours after the onset of the symptoms. It seems
to be due in some cases to a lack of oxj-gen. Eleven
cases showed acetonuria, and only two did not show dia-
cetic acid in the urine, and in one of these the test %vas not
made for it. The only marked anatomical lesion found
in the four autopsies was the extreme fatty degeneration
of the liver and the muscles. From the study of these

July 1 6, 1904]

MEDICAL RECORD.

107

cases it can be stated that the symptoms are not the re-
sult of anaesthesia, operation or shock, unless in the
presence of certain underlying causes still undetermined.
Especially in nervous, high-strung children, the confine-
ment, changed habits, changes in diet, homesickness,
dread of operation, anaesthesia, and the operation itself
may lead to changes in metabolism which have hitherto
not been taken into account. Greater attention should
be paid to the temperament of children entering a hos-
pital. The absence of any gross evidence of a pathologi-
cal condition may not constitute immunity from the dan-
ger of acetonuria, and possible death after operation.
Laution should be paid to those cases in which the presence
of a fatty liver is suspected. Special care should be ex-
ercised in those cases which show extensive degenerative
changes, such as is seen, for example, in extensive infan-
tile paralysis.

Journal o] the American Medical Association, July 9, 1904.

The Crisis and Treatment of Pneumonia. — W. J. Hal-
braith does not offer his plan of treatment as a specific
l)ut claims it has materially lowered his death rate.
The hrst attention to be rendered in the ordinary cases
is a warni bath and a saline cathartic. The indications
governing the administration of quinine and iron are
as follows: When the temperature has reached 105°,
or over, 60 grains of quinine sulphate is to be administered
as the initial dose, followed in one hour by one-half this
amount, or 30 grains, and in another hour by one-half the
latter dose, or 15 grains, at which time the author begins the
administration of tincture of iron in doses ranging from
7 to 15 minims, depending on the stage of the disease
and the condition of the heart. If he sees the patient
on the first or second day of his attack, he usually begins
with 10 minims of tincture of iron, increasing it one or
two drops, or even more, each day up to the sixth or sev-
enth day, tmless the pulse remauis strong and full. He
does not believe in giving quinine in small and repeated
doses during the active stages. When the temperature
is 104° or over he gives 50 grains of sulphate of quinine
and follows the same course as given above. When the
temperatxire is 103° he gives from 30 to 40 grains, and fol-
lows the same course. During convalescence he has found
iron, quinine, strychnine, guaiacol, and cod-liver oil of
value. What has served him best are thorough ventila-
tion and sunlight, with plenty of milk, eggs, and beefsteak.

The Yellow Fever Epidemic of 1903 at Laredo, Tex. —
G. M. Guiteras reviews his experience in this epidemic, and
draws the conclusions that the results obtained through
the efforts to combat the epidemic at Laredo demonstrate
that the Stegomyia jasciata is the only means of trans-
mitting the disease. Oiling all water containers and
deposits of stagnant water was completely successful
in preventing the reproduction of mosquitos. Inasmuch
as the Stegomyia jasciata can become infected by
biting the patient during the first three days of the dis-
ease only, it is of vital importance that cases of fever
be reported at the earliest possible moment, so that they
may be screened. It is impossible to obtain good results
without a mosquito-proof yellow-fever hospital. The
difBculties of handling an epidemic are increased when
such outbreak occurs on the frontier. Arrangements
should, therefore, be entered into by treaty with con-
tiguous foreign countries, so that sanitary measures may
be carried out jointly by the countries interested. Those
residing within the sphere of influence of the Stegomyia
jasciata should be taught through the medium of the public
press to protect themselves against yellow fever by de-
stroying the means for the propagation of the mosquito
and by protecting themselves against the mosquito by
efficient screening. If the first case presenting the
slightest suspicious symptoms of that disease were
promptly made public, and the proper modem precau-
tions taken, there would be no danger of the disease
eoreading.

The Medical News, July g, 1904.

Yohimbine; Its Use in the Treatment .'of Eye, Ear, Nose,
and Throat Diseases. — J. H. Claiborne and Edward B. Co-
burn have tested the local anaesthetic properties of yohim-
bine. They regard it as inferior to cocaine in all operations
upon the eye on account of the congestion produced by it.
For the examination of the nose it was not as effective as
cocaine, because the contraction caused by it was not so
marked. It has been found useful in ear and nose work.
Its advantages may be summed up as follows: It is non-
toxic; there is long duration of anaesthesia after its use; it
does not markedly contract the tissues; the taste is only
slightly bitter; it does not cause unpleasant contraction
of the throat and mouth. Its disadvantages are that it
does not keep well: it does not contract the tissues; after
its use there are hypereemia and hemorrhage after opera-
tion; salivation is caused by its use.

The Theory of Mutation in Its Relation to Medicine. — ■
Jonathan Wright declares that evolutionary science is

drifting in the direction of spontaneous generation. He
believes that the theory of mutation in biology, if it is
settled in the affirmative, will have a very important
bearing upon our knowledge of the etiology of disease.
The author recalls the declarations of De Vries, an Amster-
dam naturalist, that there are certain jumps in the life
history of species, which are really the origin of species.
He has specially studied the primrose in this regard, and
has observed changes which he calls mutations, and these
changes were so sudden and profound that he has come
to believe that all species at some time in their life history
exhibit an excessive instability from which new and dis-
tinct forms arise. The writer' does not see how this idea
in any way upsets the fundamental idea of Darwin. He
believes that "the theory of mutation" is important to
the conception of microbic disease. In the decades pre-
ceding the middle of the last century, it was the common
belief that from time to time the character of certain dis-
eases changed in their clinical manifestations; that, for
example, during a longer or shorter time, pneumonia pre-
sented sthenic types, suitable for bleeding, followed by
asthenic types when such procedures were disastrous.
Again, diphtheria is not sufficient to account for the
severity of the cases of throat inflammation with which
Hippocrates had to do. In the history of smallpox and
phthisis we know with what rapidity early races have
been all but exterminated by these diseases. Ancient
books give no record of many a scourge which has since
worked havoc among civilized nations. The writer sug-
gests that we may suppose that many diseases as the re-
sultants of primordial changes in the cell and the micro-
phyte entered in the dark ages upon a period of mutability
similar to the primrose in Holland after it was carried
there from America in 16 13. In the pre-Renaissance,
diseases seem to have originated with a shock or jvimp,
since that time being more or less constant except for
the minor changes in type. Just as with plants, they
may have been formed from a mother disease which may
still exist. It is in the period of upward of 1000 years
after the fall of ancient Rome that we seek the origin of
smallpox, scarlet fever, measles, whooping-cough, influenza,
possibly even syphilis. The newer the disease, the more
limited' its range among animals. Phthisis and pneu-
monia are coeval with the dawning of the history of man ;
diphtheria can be traced back to the Babylonian Jews.
Reports of the influenza were the first to emerge from
the obscurities of the dark ages. These diseases are
widespread in the animal world, but syphilis, srnallpox,
whooping-cough, scarlet fever, measles, of later historical
mention, are also markedly less widespread in the animal
kingdom. As to spontaneous generation, the writer does
not'believe that the phenomena, both biological and his-
torical, of microbic disease necessitates its assumption, and
we have little ground for this theory in facts hitherto
presented. He believes that whatever may be the trend
toward this view, the labors of Lowenhoeck, Spallanzanni,
Virchow, Tyndall, and Pasteur, have definitely thrown
the burden of proof on its future advocates.

American Me dicitte, July 9, 1904.

Gangrene of the Finger Caused by CarbolicTAcid. —

George Erety Shoemaker believes that not enough atten-
tion has been given to the danger of producing gangrene
by the use of even comparatively weak solutions of car-
bolic acid applied as a dressing for a number of hours. It
has been proved that the use of full strength of the acid
is not necessary to produce gangrene. In using dilute
solutions on a finger, it seems to be necessary for the
production of gangrene that the entire finger be sur-
rounded bv the solution and be tied up in it for not less
than 24 hours. The literature furnishes a number of
such cases. In most cases the eft'ect is painlessly pro-
duced bv a dressing kept moist for about 24 hours, and the
strength of the solution employed may be from i per cent,
to 5 per cent. The result is not due to tight bandaging;
the' dilute solution is capable of producing the effect, and
gangrene does not always follow the application. It has
been shown experiment'ally that the death of the part is
due to chemical action and that other diluted chemicals
may produce the same effect if applied by a moist com-
pre'ss for 20 to 24 hours. The same solution does not
always produce the same result. Caution in regarS to
this "matter is especially necessary in dermatology and
in minor surgery.

Concerning the Invasion Period of the Malignant Esti-
voautumnal Tertian Malarial Parasite. — Thomas W. Jack-
son states that it seems not at all imlikely, as contended
by a number of observers, that the period of incubation
of malarial fevers is a variable one, and that the variation
is an extreme one, depending upon certain ill-understood
conditions of the subject of inoculation, and the stage and
variety of the inoculated parasite. The writer reports
eighteen cases, however, which seem to support the propo-

io8

MEDICAL RECORD.

[July 1 6, 1904

sition that, under the same conditions, the period of incu-
bation for a number of individuals inoculated by mosqui-
tos with the same malarial parasites, at approximately
the same time, varied but slightly. After a careful study
of these cases, the writer feels justified in stating that:
In an epidemic of eighteen cases of estivoautumnal
fever (of the malignant variety) which occurred in Troop
A, Sixth U. S. Cavalry, in the Philippine Islands in April,
1902, the invasion or incubation period was between ten
and eleven days. The author believes that the inoculat-
ing mosquitos in this epidemic obtained the malarial para-
sites probably from native Filipinos who had previously
been in the vicinity, it being a fact well known and proven
that the natives suffer extensively from malarial disease,
in both its active and latent forms.

The Treatment of Gallstones Found as a Coincidence in
Abdominal or Pelvic Operations. — John G. Clark presents
the following conclusions: (i) The usual statement
that 95 per cent, of gallstones produce no symptoms is
fallacious because it is drawn from an autopsy and
dissecting-room statistics. (2) Recent researches .point
very strongly to the bacteriological origin of gall-
stones. (3) Bile is not bactericidal, for in the ma-
jority of cases of cholelithiasis microorganism of a more
or less pathogenic nature are discovered. (4) Under
these circumstances, many more or less vague symptoms
attributed to gastrointestinal or general constitutional
disturbances may arise from to.xins elaborated around
these foreign bodies in the gall-bladder. (5) All clin-
icians admit that there is a wider hiatus in the clinical
symptoms between the early formation of gallstones and
the so-called classic attacks of biliary colic with jaundice.
(6) Abdominal surgeons should make a most careful
record of all gastrointestinal or hepatic symptoms and
other v'ague epigastric pains and associate these with an
examination of the gall-bladder with a view to estab-
lishing a further link in the symptomatology of chole-
lithiasis. (7) As cholelithotomy in a large series of
cases has been attended with less than 2 per cent,
mortality, the coincident removal of gallstones with
some other abdominal operation is not a hazardous
undertaking. (8) In the author' s cases, more than 50
per cent, have shown symptoms which could be un-
questionably or with great assurance attributed to the
presence of gallstones. (9) This coincident operation
should be dictated by the most careful judgment, for
if the patient is in a critical condition from a prolonged
operation, or the primary operation has been a septic
one, this extra operation may be attended by serious
results.

Xew York Medical Journal, July 9, 1904.

The Home Treatment of Pulmonary Tuberculosis. — ■

E. Fletcher Ingals says that in at least two-thirds of the
cases of pulmonary tuberculosis recovery ensues, for
statistics showed that only 12 per cent, die of this dis-
ease, and autopsies showed that in 25 per cent, recovery'
froni it had taken place. He believed the so-called anii-
septic treatment was often beneficial, the open-air treat-
ment equally so, and forced feeding was more important
than either, while tonics, digestive agents, and anodynes
that did not interfere -n-ith the ordinary functions of the
body were also of much importance All of these should
be combined and the patient placed in a good climate;
when the latter was impossible much could be done at
home. He then reported a case in which open air living
could not be secured, and which illustrated the eflfects
of home treatment, \rith as liberal feeding as possible,
aided by tonics and digestive agents, anodynes to pre-
vent excessive cough, and antiseptics in large doses. A
second case was cited to illustrate the benefits of the open-
air treatment.

Effects of the Dry Carbonic Acid Gas Bath on the Cir-
culation and on the Diseased Heart. — Achilles Ro.se gives
a description of his bathtub, and since he could not
find in the literature a record of the effects of the dry
carbonic acid gas bath on the number of pulsations,
one was presented from his case book. The rapidity of
the whole blood circulation in the superficial vessels
increases during the bath, and this was sho^\Ti bvthe in-
creased strength and volume of the radial pulse. The
pulse of the bather, within a few minutes after having
entered the bath, resembles a pulse stimulated by alcohol.

The Unhealthfulness of Noise.— J. A. Guthrie. U. S.
N., asks what objections could be made against the state-
ment that noises create a disturbance of the nervous
elements to such degree that they should be given a place
in the category of disease causations ? When a healthful
condition of the nerve exists, we bear a greater amount
of nt-rvous shock \\-ith impunity; but by frequent repe-
titions of this shock, we are rendered less able to with-
stand the resulting jar. The author instances certain
facts to prove that sudden noise is disconcerting.

The Lancet. July 2, 1904.

The Treatment of Hemorrhoids and Allied Conditions
by Oscillatory Currents of High Tension. — T. J. Bokenham
bases his experience on 1 18 cases. It seems to be admitted
generally by all who have put matters to the testt hat (i)
Doumer's method is striking and quickly successful in
cases of sphincter fissure and in healing the small fissures
so often associated ^ith hemorrhoids; (2) it is valuable
in relieving pruritus ani associated ^-ith similar conditions;
(3) its value in the treatment of external and internal
piles is greatest in early cases which do not exhibit ex-
cessive hj'perplasia and thickening of the tissues ; (4) in
cases of very old standing accompanied by much hyper-
trophic change and infiltration of the hemorrhoidal tissues
the treatment gives poorer results, and at best has to be
persevered in for long periods.

Accidental Vaccina of the Nasal Cavity. — W.H. Bowen
reports such a case occurring in a woman who was nursing
her baby, who had been successfully vaccinated. The
mother had not been vaccinated since she was a baby
Anyone who has watched a baby, either taking the breast
or being carried in the mother's lap, remembering the
restless way in which babies "claw" at everything about,
and with special frequency the mother's face, ■will readily
imderstand the ease with which inoculation was brought
about Of forty-six other cases of accidental vaccination
which the author has found reported, thirty-one were on
the face, one on the tongue, eight on the trunk, and fotir
on the limbs. The only other case of accidental vaccina-
tion of the nasal cavity was reported in the Birmingham
^ledicat Refiew {or 1903.

Use of Sodium Arseniate Hypodermically in Tsetse-fly
Disease in Cattle. — Edward J Moore says that some
months ago the Government of Southern Nigeria estab-
i shed an experimental farm with the intention of teach-
ing natives to use cow's milk as an article of diet for their
children and thereby to put a natural check on twin mur-
der by removing the reason on which the practice is based,
viz., the inability of most ill-fed women to rear two chil-
dren. Twenty-two cattle, principally West Indian, were
established there and, after one month, began to show the
first signs of the disease. Fowler's solution of arsenic was
administered in one-drachm doses three times daily with-
out improvement. Larger doses of one ounce were at-
tempted, but had to be discontinued because they in-
creased the already existing tenderness of the mouth to
such an extent that the animals refused to take food and
their general symptoms became aggravated. Under
these circumstances he prepared a one-per-cent. solution
of sodium arseniate, rendered slightly alkaline, and select-
ing the worse case injected one ounce of this hypodermi-
cally on two occasions at an inter\'al of one week. The
beneficial effect was marked and immediate.

Non-flagellate Typhoid Bacilli. — J. W. W. Stephens'
method for staining nagclla with silver was a modification
and simplification of van Ermengem's method, and he had
constantly got positive results with it, so that he felt
secure in describing it last year. Shortly after having
done so he was surprised at being \mable to stain flagella
in a culture of typhoid bacilli which he had used for demon-
strating the method. Further experimenting made him
feel justified in concluding that his failure to stain the old
cultures was due to the fact that there was no flagella
there to stain. He therefore concluded that we may
have non-flagella tj'phoid bacilli. The bearings of this
observation may be of interest, (i) It may be necessary
to pass a bacillus, e.g. Bacillus dj'senteriae (Shiga),
through an animal or to examine freshh' isolated bacilli
before we can be quite certain that they do not norinally
possess flagella. (2) The typhoid bacilli which were ex-
amined above, and which he believed did not possess fla-
gella, were said to "react normally " in tj-phoid agglutina-
tion tests. If this was so then flagella could not be an
essential factor in this phenomenon.

British Medical Journal. July 2. 1904.

Pneumococcal Appendicitis and Peritonitis. — Lauriston
Shaw and Herbert French describe the case of a girl
aged eighteen years who, when she was admitted to the
hospital, was too ill to operate on. She died a few hours
after admission. Autopsy seemed to disclose the con-
dition of primary acute appendicitis with general peri-
tonitis Cultures taken from the appendix and from
the peritoneal lymph yielded an almost pure growth of
pneumococci. The case is apparently one of primary
pneumococcal appendicitis, associated with pneumo-
coccal peritonitis, and the authors think it worth re-
cording.

The Leishman-Donovan Body in Ulcerated Surfaces. —

Patrick Manson and George C. Low report that in the
infiltrated areas of 3 small intestinal ulcer, and in an
ulcer from the large intestine. Leishman-Donovan bodies,
few in number but unmistakable, have been found.

July 1 6, 1904]

MEDICAL RECORD.

109

They were inclosed in cells. In sections of liver, spleen,
and lymphatic glands the position of those bodies is
doubtless, in the majority of instances, intracellular.
The writers have never seen the parasites in the red
blood corpuscles in sections or otherwise. Wright and
James have foimd these bodies on a similar organism,
m ulcers of the integuments (Oriental sore), Christophers
in intestinal ulcers. The writers ask if failing the dis-
covery of any other means of exit from the body, may
it not be that the normal route of escape from the para-
site is by an ulcerated surface? It is seen from these
observations that these parasites may escape by the in-
testinal canal.

Intravesical Separation of the Urine from Each Kid-
ney. — B. G. A. Moynihan speaks of two methods of ob-
taining the urines from each kidney separately — by
catheterizing the ureters, thus obtaining the urine be-
fore it has entered the bladder, or by creating a septum
in the middle of the bladder in such a way that the
urine from each ureter is confined to its own side of the
bladder frona which it is drawn through a small catheter.
For the last method, the first perfectly efficient instru-
ment was made after some modifications of the original
pattern by Luys of Paris. It is made so that a thin
india rubber sheathing is raised up, forming a septum. The
lateral pieces, fitting on to the sides of the central piece,
consist of two catheters having several eyes. Each
catheter drains its own side of the bladder after the sep-
tum has been created. Another perfectly satisfactory
instrument is that of CatheHn of Paris. This has a leaf
or septum of india rtibber. This instrument presents
no difficulty in the introduction, but if the bladder is
small and the septum is pushed fully into the bladder
it will twist to one side, and the partition will be defective.
Luys' instrument is of no value unless the bladder be
fairly normal in size and position. The writer is at
present in favor of the use of Luys' instrunient for the
female, and of CatheUn's for the male, though he adds
that a more extended experience may modify his opinion.

Pads upon the Finger Joints and Their Clinical Rela-
tionships. — .Vrchibald E. Garrod defines these pads on
nodules as excrescences, which are almost confined to
the dorsal aspects of the interphalangeal joints of the
proximal row, and are only very rarely seen upon the
terminal joints of the fingers. There is no striking sym-
metry in their distribution. They vary in size from
that of split peas to that of the halves of hazel nuts.
They are usually central in position, though they may
incline to one or other side of the joint. Sometimes the
lumps are quite painless, but more often pain is com-
plained of. especially when the fingers are fle.xed. They
are doubtless mainly composed of fibrous tissue. There
does not appear to be any connection between these
pads, and any of the morbid conditions which are usually
grouped together under the names of rheumatoid or
osteoarthritis. Two elderly patients, however, did have
well-marked Heberden's nodes in addition to the pads.
There is doubtless an intimate connection between
Dupuytren's contraction and these pads. At least six
out of twelve patients showed Dupuytren's contraction.
This might be styled a paragouty lesion. But the con-
nection of these pads with gout is clearl}' less obvious
than that with Dupuytren's contraction. The writer
knows of no plan of treatment which is of any avail in
reducing the size of the pads. A patient who develops
them in early life appears to be liable finally to develop
Dupuytren's contraction of the palmar fascid. but aside
from this they do not seem to possess any grave prog-
nostic significance.

Deutsche mcdizinische Wochcnschrijt, June 23, 1904.

Scapular Crepitus. — Axmann describes an instance of
this rare condition in a boy of eighteen, in whom a crep-
itus gradually developed under the right shoulder-blade.
Otherwise the patient was normal and in good health.
On lifting the shoulder the crackling sound could be heard
at a distance of several yards. Passive motion fails to
elicit the noise and muscular action seems to be requisite.
A Rontgen ray picture failed to show any abnormalities.
As the patient displayed no symptoms requiring allevia-
tion, no treatment was instituted. Kuttner, in his report
of twenty-two cases thus far noted, calls attention to the
following etiological factors: bony deformities in the
scapula or thorax, the result of tuberculosis or syphilis
ankylosis in the shoulder-joint; paralysis with muscular
atrophy; abnormal synovial diverticulse. None of these
could be demonstrated in this particular patient.

A Case of Senile Dementia Accompanied by Contracted
Kidneys. — G. Lomer reports a case in .a man of fifty-six
in whom these two conditions were closely associated
and probably dated from the same cause — the presence
of an arteriosclerosis. The differential diagnosis was a
difficult matter, for during the entire period of observa-

tion, no specific ura;mic symptoms, such as vomiting and
convulsions, ever appeared. The urine showed a high
specific gravity and the amount of albumin by Esbach's
test, was 13 per cent. An albuminuric retinitis was not
present at any time. The arteriosclerosis could be ac-
counted for by a history of both alcoholism and syphilis,
and there was also a possibility that an attack of menin-
gitis at the age of thirty may have weakened the cerebral
vessels. A noteworthy point in this case was the early
appearance of the dementia, which is usually not observed
until about sixty-five. The patient was favorably influ-
enced by sanatorium treatment, and in a few months the
albumin dropped from 13 per cent, to 2.5 per cent. The
psychical disturbances were also improved. The prog-
nosis is very uncertain, however, as to the original disease;
the arteriosclerosis will resist all efforts at a cure.

Berliner klinisclie Wocliensekrifl, June 20, 1904.

Destruction of the Ear Drum by Lightning. — K. Burk-
ner calls attention to the rarity of injuries to the auditory
apparatus by lightning, of which only a few cases have
been reported. The author's patient was a boy of eigh-
teen, who was in a tower which was struck by lightning.
An aural examination showed an extensive tear in the
membrane, part of which was folded back over the handle
of the malleus. That the perforation did not occur as
the result of a fall, to which the boy was also subjected,
is shown by its contour, the slight amount of hemorrhage,
the absence of symptoms in the labyrinth, and the fact
that the only other injuries on the head were the bums
caused by the flash. It remains an undecided question,
however, whether the laceration was due directly to the
electric spark or to the shock accompanying the sudden
electrical discharge from the body.

The Value of Water in Disease. — E. Homberger dis-
cusses the importance of a plentiful administration of
water in disease processes, especially those accoinpanied.
By this method the most distant cells may be reached
and restored to their normal physiological condition.
As the conception of a cellular pathology also requires
a cellular therapy, this agent seems to be the most ra-
tional means to attain the end. During the course of a
fever, there is an insufficient quantity of water present
in the system, and this the body is slow in giving up, re-
.sulting in a diminished quantity of sweat and urine.
Perspiration, the author claims, is only restored when the
temperature of the body begins to drop and the super-
fliious water is no longer needed. This is contrary to the
usually accepted opinion. Although water is by no
means a panacea, it is of great value in all those diseases
in which the toxins have circulated in the blood for a con-
siderable period of time. But when these rapidly leave
the circulatory system and unite with the cells, this agent
is of little avail.

M nnchener mcdizinische Wochcnschrijt. June 21, 1904.

Herpes Zoster in Croupous Pneumonia. — Riehl observed,
among 481 cases of croupous pneumonia, that a well-
localized herpes zoster developed in 129 — about 27 per
cent. This, however, is considerably less than the number
stated by other authors, who report about 40 per cent.
The affection seems to afflict the male sex more often than
the female, and usually appears on the third or fourth
day of the disease. The author calls particular attention
to the localization of the eruption, which is most marked
over the distribution of the second and third branches of
the trigeminus, and especially the infraorbital nerve.
It is rarely found in the area of the first branch, and only
on the neck, trunk, or extremities in exceptional instances.
Pneumonias in children and the aged usually run their
course without any herpes eruption. Mild cases of pneu-
monia are characterized by an extensive eruption, while
the severest cases are most always free from this compli-
cation.

Orthodiagraphy and Percussion of the Heart. — Schule
has studied, for purposes of comparison, these two methods
for mapping out the boundaries of the heart. The former,
in which the determination is made by means of the a:-rays,
was introduced by de la Camp and Moritz, and has
also been used by a number of other observers, all of
whom are in agreement as to the results obtained. The
authors find that the cardiac area as mapped out by the
ordinary methods of percussion does not exhibit any
appreciable variations from that determined by the use
of the .r-ravs. Percussion need not be superseded by the
rays, but m doubtful cases the ideal procedure would
consist in a verification of the results obtained by per-
cussion, by an examination with the *-rays. The latter
is undoubtedly a most efficient secondary diagnostic aid.

An Unusual Injury to the Orbit. — F. Salzer reports an
interesting case in which a bit of leather whip lash about
i>2 cm. long remained imbedded in the orbital cavity
for a period of three weeks without being discovered.
The man had been struck in the upper lid, which pre-

MEDICAL RECORD.

Utdy 1 6, 1904

sented a small wound. The eye was much contused but
the wound healed promptly. Suppuration followed later
on, but the probe failed to detect any foreign body in the
discharging sinus until about a week afterward, the very
much softened fragment of leather was extracted from
the wound. The author accounts for its entrance by the
fact that on the day the injury occurred, the weather was
very cold and the leather was frozen stiff and probably
covered with ice, which faciliated its entrance into the
orbit. The patient made a good recovery.

The Relation of the Weutrophile Leucocytes in Infectious
Diseases.^J. Arneth claims, as a result of extended inves-
tigations, that the progress of the disease process may be
rendered demonstrable to the eye by the morphological
changes in the neutrophile leucocytes. To some extent
each type of infectious disease was associated with definite
changes — in one type they were well marked, in another
less so, and in a third, scarcely noticeable. The same
author now presents some further types which he has
studied, including cases of miliary tuberculosis, traumatic
tetanus, varicella, meningitis, diffuse peritonitis, pur-
pura, sepsis, typhoid pneumonia, hepatic abscess, and
hydrochloric acid poisoning. The neutrophile leucocytes
are divided into five classes, according to the division of
the nucleus into one, two, three, four, five, or more parts.
In the case of miliary tuberculosis, which ended fatally,
almost all the cells belonged to classes one and two. This
he interprets as meaning that the body is only supplied
with only the younger and immature elements for its pro-
tection. The older classes, containing a more divided
■nucleus, being practically wiped out. This picture grew
increasingly worse toward the end. Very few morpho-
logical changes were noted in the leucocytes from the
case of tetanus, the only difference noted being the in-
creased percentage of neutrophiles in proportion to the
total number of leucocytes. In a case of smallpox which
recovered, the maximum change was noted in the begin-
ning, and as the patient got better, a gradual return to
the normal took place. The two cases of suppurative
meningitis presented an anisohypercytosis, and changes
in the neutrophiles were very limited. The remaining
cases also showed characteristic changes, and the author
hopes to have his findings substantiated by other ob-
servers.

French and Italian Journals.
Continued Slow Pulse; Osseous or Calcareous Degener-
ation of the Myocardium. — M. H. Dufour observed a
patient whose pulse was from 36 to 40 a minute. Autopsy
revealed a calcareous or osseous degeneration of the
myocardium, remarkable for its extent. It involved the
mitral valve and formed a tumor the size of a nut, which
was encysted by a zone of tissue which appeared to be
■fibrous. There were several superficial areas of softening
in the brain, which accounted for the attacks of apoplexy
from which the patient had suffered. Examination of the
bulb and pncumogastrics was negative. — Le Bulletin
Medical, June 11, 1004.

Considerations of 640 Cases of the Widal Reaction. —
E. Cler. C. Quadrone, and A. Ferazzi have recorded 640
cases in which the Widal reaction was found in the labo-
ratories and hospitals of Florence in 1902-03. They
found the reaction of agglutination in various non-
typhoid febrile diseases, but not in a less dilution than
1-20. They also found it in some non-febrile affections.
In 166 casesof true typhoid they found the Widal reaction
present. They conclude as follows: (i) Serum of per-
sons not having typhoid may produce agglutination like
that of Eberth's bacillus. (2) This action if observed
in a high grade of dilution, less than 1-20, may be ascribed
to the presence of the Kberth liacillus in a latent or pre-
typhoid infection. (3) In a dihition greater than 1-20
it has a diagnostic value for tyi)hoid. Absence of this
reaction does not exclude typhoid, and is du,e to the
formatios in the blood of anti-agglutinins. — Rivista
Critica di Clinica Mcdica. May 14, 1904.

Congenital Cyanosis. — Mdry states that the congenita^
cardiac lesion which occasions the cyanosis consists of two
principal lesions: Stenosis of the pulmonary artery;
mterventricular communication or Roger's sickness.
The writer describes three cases which he has lately
observed, all of which showed the same general symptoms.
When the child cries, a crisis of paroxysmal cyanosis is
precipitated. These crises occur two or three times a day,
lasting from five to ten minutes, accompanied by acute
dyspncea and convulsions. Auscultation showed a pro-
longed systolic muniiur in the middle cardiac region. In
one case the extremities were always cold. Sometimes the
axillary temperatiue drops from 2 to 3 degrees. The
blood corpuscles are greatly increased in number. The
liver and spleen are not increased in volume. The
prognosis in these cases is very bad. The children are
carried ofl by their cardiac troubles or by pulmonary
tuberculosis. Treatment should consist chieHv in observ-

ing for these little patients the general laws of hygiene.
They should be guarded from all emotion. — Journal des
Praticiens, June 11, 1904.

Contribution to the Pathology of Tabes Dorsalis —
Carlo Fantiggia states that most modem authors regard
progressive paralysis and tabes dorsalis as the result of
the same pathological process taking place in different
anatomical regions, in the cortex of the frontal lobes of
the brain in paralysis, in the spinal cord in tabes. Or
we may have a mixed form, involving both parts and
giving symptoms of each disease. Many consider these
diseases as a toxic effect of syphilis, yet independent of
syphilis itself. Mercimals do not give good results in
tabes, and in some cases give distinctly bad ones. These
diseases may be the i^esult of poisons produced in the
system, resulting from the same cause as syphilis, yet
which are not affected by mercury, as the late paralysis
of diphtheria, is not improved by antitoxin. Such
poisons may be elaborated by other diseases than syphilis.
The author cites a typical case of tabes dorsalis with apo-
plectiform attacks.— <?az2eHa Medica Lombarda, Ma)' 23 ,
1904.

Biological Action of the Sedative Application of the
Positive Pole as Produced by the Different Apparatus
Used for Producing the Continuous Current. — Giorlama
Mirla considers the stabile application of the anode
over the seat of pain as of great value in treating painful
affections of the ner\'es and parjesthesia^. The failures
in this method are due to the source from which the
electricity used is derived. The current must be pei"-
fectly even, because the slightest oscillations and varia-
tions in strength stimulate the ner\'e treated. The
application must begin gradually, with a very slowly
increased current, and must cease in the same w'ay.
The effects are different according as the current is de-
rived from a source whose voltage is small, or one whose
voltage is great, but reduced by the interposition of
great resistance. If the electric light current is used
there may be \arious sources of the current, and they
may vary at different times of day. When produced
by a dynamo, the current has slight oscillations and vari-
ations that, although not detected by measuring instru-
ments, are still felt by the more delicate nerves of the
human body. The author uses only the Leclanch^ cell,
or those of Ringer. — Giornale d' Etettricitii Medica, May
and June, 1904.

The Functions of the Kidney and Renal Insufficiency. —
Cauterman, after considering this subject from vaiious
points of view, speaks of the treatment of renal insuffi-
ciency. He states that the exact treatment of this af-
fection is based upon an intimate knowledge of the
phenomena of this condition. The indications are va-
rious. One should avoid introducing into the organism.
in the form of food and drink, substances with a high
molecular concentration, rich in toxins, rich in chlorides.
Fermentation and abnormal alterations of food ing^ested
should also be avoided, for a food, harmless in itself,
can become irritating and injurious, under certain con-
ditions, sitch as stagnation, etc. The compensatory
organs of the kidney should be carefully watched — the
liver the intestine," and the skin. The drugs recom-
mended for this condition should be carefully studied.
And all of the mechanical means known for diminishing
the tension of fluids in Bright's disease should be con-
sidered. — Annales de la Sociiti Midico-Chirurgicale
d'Anvcrs, March-April, 1904.

Radiotheraphy in the Treatment of Tumors of the

Stomach. —Doumer and Lemoine have treated twenty
gastric tumors by tliis method. Of these they believe
that three cases were completely and finally cured. A
fotirth is on the way to recovery, while a fifth in whom
the improvement was ver>- rapid, and in whom the tumor
completely disappeared, has had a relapse that does
not )-ield to treatment. In the other cases the tumor
has had a variable course according to the case. In all
of the cases without exception this treatment has caused
the disappearance of, or great diminution of, pain, and
this from the first application. Vomiting has ceased
or has greatly diminished, and feeding has thus become
much easier. Without any doubt the general state has
been greath' improved. Doumer and Lemoine conclude
that there are certain forms of gastric tiunors in which
this treatment has worked a complete cure, lasting so
far for a year and a half in several cases, and other forms
. in which the treatment has been incomplete in its effects,
destroying the tumor in its original place, but not hinder-
ing its extension to neighboring parts and its metastases
to distant p.arts. — Le Bulletin Judical. June 15, 1904.

Extirpation of Cancer of the Kidney. — M. A. Malherbe
described this case which came imder his observation.
The patient, a man of forty-six years, was suffering from
hematuria in September of 1903. From that time he

July 1 6, 1904]

MEDICAL RECORD.

Ill

lost considerable flesh; he was yellow, and had a cachec-
tic look The urine seemed normal, and was very abim-
dant. On palpating the right flank, a tumor was clearly
felt. It reached down to the iliac fossa, and was quite
movable. In spite of the cachexia of the patient, as
he had nothing to lose and everything to gain, Malherbe
decided to operate on February 13, 1904. There was
little hemorrhage, but an injection of artificial serum
was given. The affected kidney weighed 390 grams.
The two poles were comparatively healthy, but on the
posterior surface at about the union of the lower and
middle thirds, was a large tumor. On section the cor-
tical substance looked almost as much like tuberculosis
as it did like a new growth. But in the pelvis the new
growth was very evident. Histological examination
showed the tumor to be alveolar epithelioma or cancer
of the kidney. At the beginning of March the patient
began to improve slightly, but still had a cachectic
aspect. Finally, in April, the improvement was decided
He ate very well, and increased in weight. About April
20 he left the hospital in a very satisfactory condition. —
La Medecinc Modcrne, June 15, 1904.

Peroxide of Magnesium in the Treatment of Acid Diar-
rhoea of Adults. — Betherand and Rene Galtier declare
that the acid diarrhoeas seem to them to be the only
type that indicate treatment by means of peroxide of
magnesium. Peroxide of magnesium is decomposed
only in an acidi medium. In the stomach, hydrochloric
acid or the fermentation acids decompose the peroxide
into chloride of magnesia and hydrogen peroxide, and
the latter is finally separated into water and oxygen.
The drug is administered in the form of keratinized pills
so that the specific action of the drug may play its r61e
in the intestmes. The faeces in the normal state and
under the influence of a mixed diet are alkaline or neutral,
but they become acid under the influence of a considerable
gastric acidity, which the secretions of the intestinal
glands, of the Hvcr and of the pancreas are unable to
offset. It is in such cases that the peroxide of magnesium
has given the best results. The writers then relate the
histories of several cases which corroborate the opinion
of Robin that there is in this drug an antiseptic as well
as antidiarrhoeic power, most important, when the
origin of this diarrhoea is fermentation. It is only when
the contents of the intestine are acid that the magfnesium
peroxide decomposes and sets free its oxygen. — Bulletin
General de Th^rapeuHque, June 15, 1904.

The American Journal of the Medical Sciences, June, 1904.

Mental Symptoms Associated with Pernicious Anaemia.
— William Pickett states that a composite picture of the
mental disturbance in these cases presents a shallow confu-
sion with impairment of the ideas of time and place (disori-
entation), more marked on awakening from sleep. The
patient fabricates, relating imaginary experiences of "yes-
terday " in a circumstantial way. Illusions, particularly
of identity, are common. Hallucinations appear at times,
pertaining to any of the senses. Based upon these, per-
secutory delusions arise which are usually transient.
Thej' may persist for considerable periods and be thus,
somewhat fixed. They may be even systematized. This
psychosis is mainly an abeyance of mind. It rarely
presents the spontaneous excitement by which some
types of confusion seem to merge into true mania. The
term amentia seems appropriate for it. Korsakoff's
disease and folic Brightique resemble it closely.

The Relation of Cells with Eosinophile Granulation to
Bacterial Infection. — Eugene L. Opie concludes that cer-
tain bacteria (bacillus tuberculosis, bacillus cholera; suis),
producing somewhat chronic, fatal infection in guinea-
pigs, cause the eosinophile leucocytes gradually to dis-
appear from the circulating blood. The study of dead
tissues gives little indication of the behavior of the eosino-
phile leucocytes during the course of bacterial infections.
After the inoculation of an organism producing an infec-
tion from which the animal is capable of recovering,
eosinophile leucocytes disappear from the peripheral
<;irculation. to a proportion of less than 190. The number
then increases for a few days, after which it again becomes
normal. When bacteria are introduced into the peri-
toneal cavity of the guinea-pig, the large mononuclear
and eosinophile cells contained in the peritoneal fluid,
form compact clumps, which adhere in great part to the
surface of the omentum, so that for a time eosinophile
cells have almost completely disappeared from this fluid.
After about an hour they again appear. Eosinophile
cells, rarely if ever, act as phagocytes, ingesting bacteria.
Eosinophile leucocytes are ingested by large mononuclear
cells (inacrophages). In cases of severe bacterial ' in-
fection, eosinophile myelocytes accumulate in the spleen
and may be found in the circulating blood, within from
two tc four hours after inoculation, showing that these
elements are derived from the bone-marrow and are not
found in the spleen. Bacteria exert a chemotactic in-

fluence upon cells with eosinophile granulation, attract-
ing them from the bone-marrow into the blood, and from
the circulating blood to the site of inoculation.

Traumatic Intestinal Rupture, with Special Reference
to Indirect Applied Force. — Emanuel J. Senn calls atten-
tion to internal injuries with no manifest external lesions.
These injuries are most frequent in men and young
adults, on account of their greater exposure to injury.
Generally speaking, blows above the level of the umbilicus
are unlikely to cause intestinal injuries. Pathologically
the injuries may be classified as (i) contusions; (2) rup-
ture; incomplete, complete. Contusions may be of all
degrees. Incomplete ruptures, when one or two of the
tunics are torn, in all probability are frequent; however,
according to pathological investigation, they are con-
sidered rare. Complete ruptures, when all the tunics
are ruptured, are more often brought to view on the
operating table and in the post-mortem room. They are
usually single, but may be multiple. As intestinal rup-
ture is usually the consequence of a severe trauma in the
neighborhood of the sympathetic centers, the classical
symptoms of shock generally develop. Retroperitoneal
emphysema signifies injuries to the duodenum or colon.
Fecal matter is less apt to escape than gas, but the latter
may escape in very small quantities. Vomiting is con-
sidered of great diagnostic importance by many. As to
prognosis, Siegel gives the following statistics; In cases
operated upon in the first 4 hours, the mortality is 15.2
per cent. ; in the first 5 to 8 hours, the mortaUty is 44.4
per cent.; in the first 9 to 12 hours, the mortality is 63.6
per cent.; in those operated upon later, the mortality is
70 per cent. The writer states that in all cases of ab-
dominal contusions the prognosis should be guarded, and
the patients ought to be kept under careful observation.
When there is the least suspicion of rupture, immediate
laparotomy should be performed. The writer advises
the incision made through the hnea alba below the umbiH-
cus, as giving a better survey of the abdomen. The bowel
should be examined methodically from a fixed point till
the lesion is found. When for some reason operation
cannot be performed, and an expectant course is followed
in simple contusion or in cases of ruptured intestine, the
patient should be placed at rest with an ice-bag on the
abdomen. Nourishment should be given only bv rectal
enemata. Opium is indicated to diminish peristaltic
action of the bowels.

The Envelope of the Red Corpuscle and Its Role in-
Haemolysis and Agglutination. — S. Peskind gives the fol-
lowing r&um^; Various facts of an historical, chemical,
and physical character show that the red blood corpus-
cles possess an envelope. From the action of hydroxy-
lamine hydrochlorate, it appears most probable that the
envelope is not a differentiated membrane, but a part of
the stroma which is condensed to form the surface laj-er
of the corpuscle. The envelope is hcemoglobin-free and
consists of nucleoproteid cholesterin, lecithin, and mineral
constituents. It is elastic, smooth, and apparently
pot. esses a certain glaze which presents the agglutination
of normal corpuscles with each other and makes them less
accessible to the action of toxins. Agglutination of blood
corpuscles is due to an effect on the envelope produced by
various biological products and chemical reagents whereby
the envelope is made sticky. .Agglutinins probably lower
the resistance of the blood corpuscles forward toxins and
other agents. From the fact that in nature they almost
always occur in company with a hasmolysin, it is suggested
that ' the agglutinins bear some cooperative relation to
the haemolysins similar to that existing between the in-
termediarv bodv and the complement. The "resistance"
of blood corpus'cles depends in large part upon the con-
dition of the envelope. Toxins of disease cause the en-
velope to deteriorate, either partly or completely. " Vac-
uohzation of the hasmoglobin " can be explained satis-
factorily on the assumption of a minute lesion in the en-
velope, which allows the surrounding fluid to enter and
thus permit, of a locaHzed laking at this point. The func-
tion of the envelope is, in part, to make possible various
metabolic processes, principal among which is the com-
plex process known as internal respiration. Another
important use is to protect the corpuscles from deleter-
ious substances. But the very chemical constitution of the
the envelope may at times serve for the undoing of the
corpuscles.

Health of the Russian Army. — An official report from
Manchuria states that up to June 26 the officers and
men in hospital reached a total of 7.136 per cent, and
3.943 per cent, respectively of the whole force. After
the rains began the percentage of officers in the hospitals
increased to 8.383 and of the men to 4.646. The pro-
portion of infectious cases rose from 2.19 to S.52, in-
cluding 1.99 percent, of dysentery.

112

MEDICAL RECORD.

[July i6, 1904

Materia Medica, Pharmacology, and Therapeutics.
Inorganic Substances. By Charles D. F. Phillips,
M.D., LL.D. (Abdn. and Edin.), F.R.S. and F.R.
C.S. (Edin.). Hon. Fellow Medico-Chirurgical College,
Pennsylvania; Member of the Academy of Medicine of
America; Examiner in Materia Medica, University
of Aberdeen, Late Examiner in the Universities of
Edinburgh and Glasgow; Member of the Physi-
ological Society of London; Late Lecturer on Materia
Medica and Therapeutics at the Westminster Medical
School. Third Edition London, New York, and
Bombay: Longmans, Green & Co., 1904.
This is a book of exceptionally practical value, full of
useful suggestions, and one that cannot fail to be of
ser\'ice to the physician in his fight with disease. The
greater part of each section is devoted to the indications
for the therapeutic employment of the drug under con-
sideration, though sufficient space is accorded to a dis-
cussion of physiological action and to the preparations and
dosage of the remedies. The author speaks out of his
own experience in the treatment of disease, and this
gives to the book the charm and value of the personal
touch associated with the clinical lecturer; but at the
same time he does not ignore the discoveries of others in
the same field.

The chief fault with the book is the lack of system in its
arrangement. Under the heading of "water," for ex-
ample, sun baths and air baths, the Finsen light, and
electric baths are treated of. and as there is only a thera-
peutic index and none of remedies the matter is prac-
tically inaccessible. An index of remedies would have
obviated this objection ; one was in the former edition, and
we cannot but think the author has made a mistake in
omitting it from this edition.

Le Malattie DEI Paesi Caldi, Lord Profilassi ed
Igiene, con un' appendice; La vita nel Brasile. Rego-
lamenti di Sanitd pubblica contro le infezioni esoticne.
Pel Dottor Carlo Muzia. Con 154 incisioni en tavole.
Milano: Ulrico Hoepli, 1904.
The author of this volume is a surgeon in the Italian
Navy. The subject is treated imder seven heads : General
diseases, local diseases, diseases and lesions produced by
animals and animal parasites, intoxications, cosmopolitan
diseases occurring in the tropics, insolations, and hygiene
of the tropics. The work is copiously indexed, and
contains a bibliography of the principal works on the
subject. While the size of the work precludes any
monographic presentation, the terseness of expression
enables the author to present much in the space at his
disposal. The illustrations relate chiefly to the micro-
organisms of the various diseases, and corresponding
to the disproportionately large number of parasitic
diseases the illustrations of the animal parasites are
numerous. Maps are also given showing the geographical
distribution of several of the more important diseases .
Physiology and Pathology of the Uri.\e. With
Methods for Its Examination. By J. Dixon Mann,
M.D., F.R.C.P., Physician to the Salford Royal Hos-
pital; Professor of Forensic Medicine in the Victoria
University of Manchester. With Illustrations. Lon-
don: Charies Griffin & Co., Ltd.; Philadelphia: J. B.
Lippincott Company, 1904.
And still they come! " Another book on the virine! "Wer
reitet so spiit durch Nacht und Wind ? " It is an English-
man this time, but what he has given us is a genuine sur-
prise. A book not of the type" of the now so frequent
'guides to the examination of urine." It differs from
them in its thoroughness, completeness, and up-to-dateness.
Some of the constituents of the urine, irrespective of
their chemical constitution, have been grouped together
to facilitate their study ; a description is furnished of the
systemic conditions in which each urinary component
appears in anomalous quantities; the more important
pathological states, recognizable by specific alterations
in the urine, are separately dwelt upon; and the results
of the latest studies in metabolism, so far as affecting the
urine, are given in just sufficient minuteness to be of
real assistance to the investigator.

The titles of the various sections will demonstrate the
practical value of the book: General Characteristics of
the Urine, Inorganic Constituents, Organic Constituents,
Amido and Aromatic Acids, Carbohydrates, Proteids,
Nitrogenous Substances, Pigments and Chromogens,
Blood-coloring Matter, Bile Pigments, Bile Acids, Ad-
ventitious Pigmentary and Other Substances, Special
Characteristics of Urine, Urinary Sediments, Urinary
Calculi, Urine in Its Pathological Relations.

The subjects treatcd''upon in the section on "Special
Characteristics of Urine" being particularly useful to the
progressive clinician and impressing upon the book the

stamp of modernity, are: Reducing Power, Oxidative
Power, Proteolytic Power, Toxicity, Molecular Concen-
tration (Kryoscopy), Conductive Capacity, and Calori-
metry.

The illustrations are of the stereotype variety and
mediocre; the stronghold of the otherwise superb book
does not lie in its chapters on the microscopy of the urine.

BeRICHT UBER GaLLENSTEINLAPAROTO.MIEN AUS DEM

letzten Jahr; unter gleichzeitiger Beriicksichtigung
der nicht operirten Falle. Von Prof. Hans Kehr.
Munich: J. F. Lehmann, 1904.
This contribution to the subject of gallstone surgery
forms part of the annual report of Kehr's private sur-
gical clinic in Halberstadt, Germany. During the past
year he had the opportunity of examining over 300 cases
of cholelithiasis and performed an operation in 13^ of
Ihese. The particular points to be noted in his technique
are the disinfection of the hands with soap and water and
alcohol (no bichloride); the most stringent asepsis;
gastric lavage before operation in almost all cases ; nitrous
oxide and chloroform anaesthesia; restricted numbers
of nurses and assistants ; the use of silk and sterile gauze,
neither catgut nor iodoform gauze being employed. Al-
though Kehr does take an extreme view as to early opera-
tion, and recognizes that a so-called latent period comes
on spontaneously in about two-thirds of the cases. This
is the reason why various internal methods of treatment
are often followed by such favorable results; the latter
are post hoc, not propter hoc. Kehr has recently traced
about two-thirds of the last series of 500 cases which he
operated iipon for gallstones. About 90 per cent, of
these remained free from colic, icterus, and hernia, and
were completely cured.

The Medical News Pocket Formulary. By E. Quin

Thornton, M.D., Assistant Professor of Materia

Medica in the Jefferson Medical College. New (Sixth)

Edition, Revised. Philadelphia: Lea Brothers & Co.,

1904.

This collection of prescriptions seems to have taken well

with physicians. The diseases are printed in large type

and alphabetical order, so that reference is easy. There

are 287 pages of small type. There is a useful table of

doses, and the revision has brought the matter well up

to the times.

The Medical Epitome Series of Pediatrics. A

Manual for Students and Practitioners. By Henrv

Enos Tuley, A.B., M.D. Edited by V. C. Pederson,

A.M., M.D. Philadelphia and New York: Lea Brothers

& Co., 1904.

This little book is intended as a pocket guide to the

beginner in medicine. It deals with the pathology,

diagnosis, and treatment of the diseases common to

children. After each chapter a series of questions and

answers are inserted to bring out the most valuable

points. It also gives many points on the differential

diagnosis. The author has contributed very frequently

to pediatric literature and is entitled to a hearing. The

chapter on infant feeding is quite complete. In a future

issue the vital points concerning the brain and nervous

system should be incorporated, as well as a chapter on

intubation.

Lectures on Clinical Psychiatry. By Prof. Emil
Kraepelin. Authorized Translation from the German
by Dr. James Johnstone. New York: Wm. Wood &
Company, 1904.
This is a volume of 300 pages containing thirty clinical
lecturers on the commoner varieties of insanity, such
as Melancholia, Manic-depressive Insanity, Dementia
Praecox, General Paresis, Epileptic Insanity, Puerperal
Insanity, Insanity after acute diseases. Paranoia, the
insanities of alcoholism, morphine and cocaine, Trau-
matic Insanity, Imbecility, Cretinism, Different Forms of
Delusion, Compulsory Ideas and Irresistible Fears and
Morbid Personalities. The lectures are simple, readable,
and will undoubtedly be very acceptable to American
physicians. During the last few years the classification
of Kraepelin and the nomenclature which has grown out
of the classification have taken a firm hold upon young
American psychiatrists, and, although at the present
time there are indications that the teachings of Wernicke
are gradually gaining ascendency, still the followers of
Kraepelin are many in this country. The book makes
no attempt to cover the entire field of psychiatry but
rather to deal with the familiar forms of alienation. Nor
is there any space devoted to discussions of classification
or theories of the pathogenesis of insanity. The general
practitioner, especially if he is not familiar with the
author's views, will find this volume of great aid in the
interpretation of mental cases encountered in his practice,
and the specialist will find it a valuable clinical com-
pendium, to be used in connection with the treatise on
msanity by the same author or any of the other standard
works.

July i6, 1904]

MEDICAL RECORD.

1^3

AMERICAN GYNECOLOGICAL SOCIETY.

Twenty-ninth Annual Meeting, Held in Boston, Mass., May

24, 25, and 26, 1904.

Tuesday, May 24— First Day.

The society met in the Boston Medical Library under the

presidency of Dr. Edward Reynolds of Boston.

An address of welcome was delivered by Dr. Charles M.
Green of Boston, which was responded to by Dr. Henry
T. Byford of Chicago.

Treatment of Gallstones Found as a Coincidence in Ab-
dominal or Pelvic Operations. — Dr. John G. Clark of
Philadelphia stated that among the imsettled questions
in abdominal surgery, the treatment of gallstones fovmd
as a coincidence in abdominal or pelvic operations might
be considered a debatable one. He followed the plan at
present of removing gallstones which were found in the
course of another operation, if the patient's condition
permitted of this extra operation. Although it was stated
that 95 per cent, of gallstones produced no symptoms, he
believed that this statement should not be applied to cases
as one met with them at the time of an operation. In his
review of recent literature he had been especially im-
pressed with the fact that knowledge of the early stages
of cholelithiasis was verj- indefinite, and that many cases
which came to operation for more or less urgent s)-mptoms
did not have the clinical symptoms of colic and jaundice,
as usually taught in medical schools. In view of this
hiatus in the early history'of this disease, he believed that
many symptoms now attributed to gastralgia, indigestion,
functional disturbances of the gastrointestinal tract, etc.,
would, as knowledge increased, be ascribed to the presence
of gallstones with associated infection, which was so fre-
quently found in cholelithiasis.

In referring to the etiology of gallstones, he said that
three facts had been prominently established: (i) That
the bile was not bactericidal. (2) That the microorgan-
isms in the gall-bladder were predisposing, if not absolute,
causative factors in the formation of gallstones. (3)
When gallstones were present in the gall-bladder, infection
in that viscus was much more likely to take place.

He mentioned three general avenues through which
infection might enter the gall-bladder, (i) From bac-
teria circulating in the genital blood stream and reaching
the liver through the hepatic veins; (2) by the direct
passage of bacteria into the common bile duct from the
duodenum; (3) by the transportation of bacteria from
the intestine through the portal circulation.

He then recurred to the frequently quoted statement
that 95 per cent, of gallstones did not produce symptoms,
and showed from his own series of cases that in at least
50 per cent, there were varj'ing symptoms from undoubted
attacks of colic and jaundice to less pronounced gastro-
intestinal symptoms. To justify operative intervention
in cases which were not producing well-defined symptoms,
the mortality and morbidity should be a very low one.
In his own experience no death had occurred, nor had
there been any serious complication referable to the
secondary operation. In lieu of the fact that the addi-
tional operation did not seriously jeopardize the life of the
patient, and also because he had seen two patients die
from cholelithiasis a year or more subsequent to an ab-
dominal operation, in which, had the routine exploration
been made, the gallstones might have been easily removed,
he believed that the best interests of the patient would be
conserved if the gallstones were removed as a secondary-
part of another operation, in the event of their being
found. He appended the history of twelve cases to his
paper, in which the various operative points, as well as
the significant facts in symptomatology, were elaborated.
Dr. R. Stansbury Sutton of Pittsburg said that gall-
stones did not always produce symptoms which demanded
or justified resort to operation. If they were encoiuitered

during the course of another operation, they had better
be removed.

Dr. George M. Edebohls of New York had occasion at
one time to operate on a woman who presented marked
dyspeptic symptoms. In addition, she had movable
kidney, chronic appendicitis, and induration in the region
of the gall-bladder. He anchored the kidney, removed
the appendix through a lumbar incision, pulled the gall-
bladder into the lumbar wotmd, and found the stone about
four or five centimeters in length, pear-.shaped, and nearly
filling the gall-bladder. The attending physician w-as
positive that the gall-bladder did not produce symptoms
of stone in it. He would not let him remove the stone
from the gall-bladder. A year later he opened the woman's
abdomen for some other condition, making an incision
near the gall-bladder. He investigated the gall-bladder,
found it was perfectly healthy, and that the large stone
had either passed or had been dissolved. The treatment
after the previous operation consisted of the use of olive
oil for about a month, and whether this had anything to
do with the passage of the stone, he did not know. At
any rate, the stone had disappeared and had left no trace
of its former existence.

Dr. A. Palmer Dudley of New York emphasized the
importance of looking beyond the gall-bladder for trouble.
He believed that stones were formed in the liver ducts
themselves, and that from a stagnant circulation cholester
in nuclei formed, and that only a small proportion of
stones were foimd in the gall-bladder. He would not
hesitate to go into the center of the liver. In fact, in the
last case he had, in which the diagnosis of gallstones had
been made by a medical confrere, he boldly went into the
gall-bladder, but found no stone. He found the duct
dilated ; he went five inches into the right lobe of the liver,
as far as he could reach with his finger, and packed the
liver full of iodoform gauze, put an apron of gauze over
it, and the patient was well to-day. He would explore the
center of the liver in searching for such deposits.

Dr. Brooks H. Wells of New York said that in the
last few years he had used practically the same measures
as those outlined by the essayist. A number of patients
coming under his observation had complained of obscure
symptoms, of so-called functional indigestion. In them
he found either disease of the gall-bladder, an over-dis-
tended gall-bladder from obstruction elsewhere, or trouble
referable to gallstones.. By making a small or large in-
cision, as seemed necessary, cleaning out the gall-bladder
and draining it, the patients had obtained remarkable
relief from the symptoms that were supposed to be due
to functional indigestion.

Dr. Seth C. Gordon of Portland, Me., said that when
the abdominal cavity was opened for other purposes, and
he was quite sure the patient could stand it, he would ex-
amine the gall-bladder thoroughly, and if gallstones were
found, he would remove them. He cited cases in support
of this line of reasoning.

Dr. Hiram N. Vineberg of New York said that under
the influence of the teaching of Kelly he had been in the
habit of doing what had been advocated by the essayist,
but after hearing a discussion on gallstones in the common
duct and in the gall-bladder by one of the Mayos, he had
changed his method. Simply opening the gall-bladder
and removing the stones did not effect a cure, as proven
by three or four cases that occurred in his own practice.
If the gall-bladder was diseased, however, it should be re-
moved.

Dr. J. M. Baldy of Philadelphia said that gallstones
existed in the gall-bladder for years without causing any
material discomfort, but that when infection occurred
they were liable to give trouble. There was not the slight-
est question but what large numbers of cases of so-called
stomach trouble, or chronic indigestion, sooner or later
proved to be cases of gallstones or of gall-bladder disease.
With reference to removing gallstones when operating
for some other intraabdominal condition, the surgeon

114

MEDICAL RECORD.

[July 1 6, 1904

should consider the physical condition of the patient, the
surroundings, etc., and as to whether the patient was
willing to imdergo the additional risk o£ a second incision
for the gall-bladder operation.

Dr. Walter P. Manton of Detroit quoted Ochsner as
saying that he had tried almost everything in the so-called
cases of chronic dyspepsia, without affording relief; yet
after opening their gall-bladders and removing gallstones
which were found, the patients were cured. Dr. Manton
had seen a number of such cases, and contended that the
removal of gallstones, or the gall-bladder, if diseased, was
the thing to do. He did not believe there was any solvent
ever invented which could dissolve gallstones.

Dr. Beverly MacMonagle of San Francisco, Cal.,
stated that when the abdomen was opened for some pel-
vic or abdominal trouble, the operator should investigate
the gall-bladder. If gallstones had been making the
patient ill, causing dyspepsia, or if there were adhesions
around the gall-bladder, one should operate. The con-
ditions that arose in the pancreas as a consequence of gall-
bladder disease and of gallstones were serious, and if the
surgeon could do something of a prophylactic nature,
without adding to the risk of the patient's life, it was a
wise thing to do.

Dr. Clark, in closing, said the formation of gallstones
through bacteria had been clearly demonstrated by a
series of experiments. He did not believe anyone would
strongly advocate operation unless the gallstones were
producing symptoms.

Ovarian Pregnancy. — Dr. J. Clarence Webster of
Chicago reported a case of ovarian pregnancy. There
was a right ovarian irregularly rounded swelling, measur-
ing 7 by 8 cm. There was no evidence of rupture into
the peritoneal cavity. The adhesions were recent. Sec-
tions of the ovarian swelling consisted mainly of extrav-
asated blood and disseminated fragments of the chorion.
No evidence of transformation of ovarian connective
tissue into decidua was noted. It was certain that the
pregnancy did not start in a Graafian follicle.

Dr. J. Whitridge Williams of Baltimore said there
was no doubt that ovarian pregnancy occurred, but it
was the rarest of all forms of extrauterine pregnancy. In
regard to the Muellerian origin of ovarian pregnancy, he
was not quite convinced of it. While there was no doubt
that Muellerian tissue might be found in the ovary, as
mentioned by the essayist and confirmed by numerous
observers, he thought it was going too far to advance that
view in explanation of every case of ovarian pregnancy.

Dr. John T. Thompson of Portland, Me., referred to
a case of ovarian pregnancy he had reported at a previous
meeting of the society. He called attention to the nature
of the structures in which pregnancy occxirred, and to the
frequency with which rupture might occur in the early
days.

Dr. Edward P. Davis of Philadelphia removed an
ovarian pregnancy about a year ago, the histology of
which had not been completely worked up as yet, although
a diagnosis was made very early of the nature of the tumor
from the enlarged ovary. The indications were that the
pregnancy did not originate in the Graafian follicle.

Dr. Lapthorne Smith of Montreal had diagnosed
ectopic pregnancy by the clinical symptoms; had op-
erated, and had found hsematoma of the ovary. He had
said to his students that lie was sorry that his diagnosis
was wrong, because authorities maintained that there was
no such thing as ovarian pregnancy, but after hearing
what had been said he was convinced there was.

Ureterolithotomy. — Dr. J. Wesley Bovee of Wash-
ington, D. C, in a paper on this subject, gave the history
of the operation, and then discussed the size and number
«f calculi. The routes for reaching and extracting
ureteral calculi, he said, were the transperitoneal and the
extraperitoneal. The latter might be subdivided into
loin, inguinal, vaginal, rectal, sacral, perineal, and trans-

vesical. The transperitoneal route should never be the
one of election, as the danger of peritoneal infection from
the urine was too great. Of the extraperitoneal routes,
the selection would depend largely upon the location of
the calculus or calculi, although the operation of Ceci,of
removing it through the rectum, should only be considered
justifiable when the stone had practically sloughed
through into the rectum. In a class of cases characterized
by the stone having been lodged in the intravesical portion
of the duct and later sloughed into a pocket in the bladder
wall, which it had made for itself, the vaginal and inguinal
routes were the only safe ones, although in so stating he
was not unmindful of the number of cases in which supra-
pubic cystotomy had been done. He discussed the re-
moval of the calculus from the ureter, and the methods
for so doing; also the treatment of the ureteral opening.

Speaking of drainage, he stated that all ureterolithot-
omy wovmds should be drained. This was because the
urine was practically never normal, therefore rendering
wound infection probable. The possibility of urinary
leakage subsequent to operation afforded another positive
indication for drainage.

Nephrectomy for Primary Tuberculosis of the Kidney. —
Dr. Hiram N. Vineberg of New York read a paper on
this subject. Tuberculosis of the kidney, both primary
and secondary, was more frequently met with in women
tlian in men, in the proportion of about two to one. It
was different from what occurred in men ; renal tuber-
culosis in women was rarely associated with tuberculosis
of the genital organs. A cystitis in women that resisted
the topical applications of the silver nitrate solution by
the Kelly method should be looked upon with naarked
suspicion as being of tuberculous character, even though
repeated examinations of the urine should show an ab-
sence of the tubercle bacillus. The differential diagnosis of
a non-tuberculous from a tuberculous cystitis with the
aid of the cystoscope was not as reliable as the therapeutic
test outlined in the preceding sentence. Pronounced red-
deningor ulceration about the mouth of one of the ureters,
with absence of other bladder changes, was held bj' some
authorities as pathognomonic of tuberculosis of the corre-
sponding kidney; while the sign was an important one,
too much weight should not be attached to it in women.
In most cases the removal of the diseased kidney wovdd
bring about practically a cure of the descending cystitis.
He doubted the wisdom of the advice to cure the cystitis
before imdertaking the removal of the kidney in women,
owing to the fact that the disease was most frequently
primary and unilateral, the modem tests for determining
the functional capacity of the second kidney were not as
essential as in men. Catheterization of the supposedly
healthy kidney was a procedure to be avoided, when, as
was frequently the case, there was associated a tubercu-
losis of the bladder. The prognosis of nephrectomy in
renal .tuberculosis in w-omcn was exceedingly good. Of
the writer's four cases operated upon, seven, five, two, and
one and one-half years ago, respectively, all were alive and
in good health.

Dr. Joseph E. Janvrin of New York reported a case
of a woman who had been ailing for two years with what
was supposed to be a renal calculus. Before operating,
Dr. Willy Meyer examined the woman, and agixed with
him that the case was probably one of calculus in the
pelvis of the kidney, with possibly calculi in the tireter.
The kidney was removed, and it was found that the pelvis
was infiltrated with tuberculous deposits in the very early
stage. The patient made a good recovery and was well
to-day.

Dr. J. Wesley Bovee said that if one read the proceed-
ings of the late meeting of the German Congress, he vould
be impressed with the comparatively large proportion of
cases in which primary tuberculosis was found in both
kidneys, or the very small proportion in which one kidney
alone was involved. As to the indications for operation,

July 1 6, 1904]

MEDICAL RECORD.

on tuberculous kidney, the surgeon should be sure that
the opposite kidney was capable of carrying on the func-
tion of excreting urine for the whole body before he
decided to remove one tuberculous kidney. A nephrot-
omy might be done, and the kidney most markedly dis-
eased drained, without taxing the other kidney to a great
extent. As regards cystitis in tuberculosis of the kidney,
it was a late, not an early, symptom.

Dr. Philander A. Harris of Patcrson, N. J., said that
in cases of tuberculosis of the kidney it was difficult, when
the bladder was corrugated and changed by the pathology
present, to find the ureter; but by painting the entire
field of the bladder with some solution sufficiently colored
with a swab, as Prussian blue, he had succeeded in finding
the ureters in the case of a girl which he could not other-
wise locate.

Dr. Seth C. Gordon operated on a man, removing a
kidney which was situated low down in the abdomen,
painful, and bound down by adhesions. The patient
died eleven days after the operation, and post-mortem
examination showed that the man had no other kidney.
Two years afterward he removed a very large kidney from
a woman, who lived twenty-eight days after operation.
For twelve hours she did not have a single uraemic symp-
tom, nor was there a drop of urine secreted, and she died
in full possession of her faculties. Post-mortem exam-
ination revealed that she had no other kidnej'.

Dr. J. M. Baldy said it was not uncommon to have
medical men in the wards of the policlinic ask if the ureters
had been catheterized in the cases of supposed kidney
disease, and not infrequently a perfectly healthy kidney
was palpated and found on one side which utterly failed
to secrete with the patient under an anEesthetic or without
it. In some instances this failure on the part of the kidney
to secrete was imdoubtedly brought about by the in-
fluence of the anaesthetic. At any rate, anesthesia would
reduce the quantity of secretion very materially. He
had had exactly that same experience a number of times
in patients whose ureters he had catheterized, but to
whom no anjesthetic had been given.

Dr. George M. Edebohls said that some four or five
years ago he read a paper on "The Other Kidney and Con-
templated Nephrectomy." In it he advocated that
before removing a kidney an incision should be made on
the opposite side to determine by actual inspection and
palpation (i) the presence of another kidney, and (2)
its probable health, so far as could be determined macro-
scopically, before removing the diseased kidney. In
spite of the advance made in diagnosis, and its limitations
in kidney diseases, he had adhered to that rule in all
nephrectomies performed since that time, and in one case
he had saved a woman's life by so doing.

Dr. J. Riddle Goffe of New York reported a case bear-
ing on the removal of the ureter in connection with tuber-
culosis of the kidney, the patient having been operated on
by him in 1896. She was a woman of twenty-two, who
had a very large tuberculous abscess of the right kidney.
He removed the kidney and three inches of the ureter.
She made an excellent recovery, excepting that she had
a sinus which lasted four months and then healed. Pa-
tient was now a graduate nurse and in perfect health.

Dr. Edward Reynolds of Boston gave his experience of
ten nephrectomies for tuberculous disease, seven of them
being complete nephro-ureterectomies, all successful, so
far as operative mortality was concerned.

Hypertrophies and Inflammations about the Urinary
Meatus. — Dr. Robert L. Dickinson of Brooklyn read a
paper on this subject, saying that their fnqutncy, and
the suffering caused, gave them an importance out of all
proportion to their minute size. Overlooked because
hidden among folds of mucous membrane. They were
explained bj' embrj'ology. A tiny ribbon ran from the
rear of the vaginal opening forward, on each side of the
vaginal and urethral openings, across the vestibule to
disappear beneath the clitoris. This fold was persistent in

those cases in which the hymen ran forward of the meatus,
or the meatus seemed to open on the anterior vaginal
wall. This fold was enlarged by friction or traction to
produce flaps or labia, hanging out each side of the meatus.
They were fotmd only with corrugated labia. Dilated
or dilatable urethra often accompanied thim. The
urethral glands opened near the apex of the flaps. They
were long, running down into the anterior column of the
vagina. Swelling from infection differed from hyper-
trophy. The cure of chronic inflammation was only
feasible by obliteration of the glands. A fine probe,
passed to the bottom of the gland, rendered the vestibular-
vaginal surface tense; the cautery wire cut out the probe.
For piles of the meatus, the cautery wire was used after
cocaine ; for prolapse or dilatation of the urethra, resection
of the anterior vaginal wall or paraffine injections into the
urethrovaginal septum produced a sigmoid profile.

Surgery of the Female Urethra — Dr. Ely Van de War-
ker of Syracuse, N. Y., read a paper on this subject. The
urethra, he said, appeared like an insignificant part, its
vital relations were negligible, its anatomy was relative,
and acquired its importance from its related organs, but
it might be said to epitomize a large share of the sufi'ering
that woman's pelvic organs inflicted upon her. The
amoimt of disturbance caused by- a simple irritation of
the urethra to the bladder and indirectly to the kidneys
afforded striking proof of the validity of reflected nervous
disturbance.

The term sacculation was regarded as better than the
old one, urethrocele. Its major cause was mechanical,
as inflammation alone was not adequate to its production.
The lu-ethra might be said to belong to the perineal rather
than the pelvic zone of organs. The walls of the canal
depended in a meastire upon the support of the perineal
body. It was often associated with long-standing rupture
of this part. Restoration of the perineum was therefore
essential to treatment of the sacculation. When large,
an elliptical flap of the walls of the urethra was removed
and the edges brought together by fine silk sutures. Pro-
lapse of the mucous lining of the urethra the author had
generally associated with long-standing urinary troubles
of various kinds. It was, therefore, probably due to a
gradually progressive condition, and was a typical ptosis,
and complied with the general law of genital prolapse.
After removing the prolapsed portion there was a marked
tendency to recurrence unless the conditions which gave
rise to it were treated and cured. Bladder incontinence
and dribbling were often lifelong conditions. That this
was due to a defective action of the sphincter vesicae was
more than doubtful.

Stricture of the urethra, in the author's experience, was
common in women. Any condition that tended to pro-
duce linear or annular thickening led to stricture.
Specific urethritis might produce stricture, but it was not
the frequent cause alleged by some writers. Stricture of
large caliber might be located and measured by the Otis
bulbs, but never by the sound, as was recommended by
old systematic writers. Annular stricttu-e of the meatus
was the form most commonly met with. These ought to
be incised and made to heal in an open condition by the
frequent passage of the sound. Dilatation alone was too
painful and required too much time. As to eversion of
the mucous membrane at the meatus, its prototype was
the fusiform stricture of Otis, and its surest cure was by
dilatation.

Pyelitis Complicating Pregnancy. — Dr. Edwin B.
Cragix of New York read this paper (see page 81).

A Second Case of Puerperal Eclampsia Successfully
Treated by Renal Decapsulation. — Dr. George .M. Ede-
bohls of New York said the first case, reported to the
society a year ago, illustrated the immediate cure by renal
decapsulation of puerperal convulsions, recturing with
great and increasing violence after the birth of the child,
a period at which the hitherto final resource of forced

it6

MEDICAL RECORD.

[July 1 6, 1904

delivery was, of course, no longer available. In presenting
the case the opinion was advanced that resort to renal
decapsulation in the undelivered woman suffering from
puerperal eclampsia might obviate the necessity of forced
delivery. The case now reported illustrated the correct-
ness of that opinion. Renal decapsulation was performed
upon a woman pregnant near term, suffering from puer-
peral eclampsia, and almost complete suppression of urine.
The convulsions were arrested, the flow of urine was re-
established, and a threatened death from uraemia was
averted. Two daj's after all this had been accomplished,
labor began spontaneously, and living twins were bom.
One child died soon after birth. The second child and the
mother were in perfect health four and a half months
after the termination of pregnancy. Renal decapsulation
thus became the rival of forced delivery in cases of puer-
peral convulsions of renal origin in the undelivered woman.
In puerperal convulsions, occurring or recurring after
delivery, it constituted the final resort when all other
measures had failed.

Wednesday, May 25 — Second Day.
Primary Repair of Lacerations of the Cervix Uteri. — Dr:
Edward P. Davis of Philadelphia read the first paper in
the symposium on this subject. Experience in fifty-three
caseshad led to the following conclusions : When the patient
was not infected and when the tissues had not been sub-
jected to sufficient violence to threaten necrosis and
laceration of the cer\'ix, one-half inch or more in extent
was present, primary closure had been followed in his
experience with good results. These cases usually oc-
curred in primiparae in whom resistance in the soft part
occasioned sufficient delay and fatigue to require de-
livery by forceps. They were also seen in cases of prema-
ture labor, whether spontaneous or induced, in which the
cervix was not phy.siologically softened for perfect dilata-
tion. They were also found in patients having spon-
taneous labor with very strong expulsive efforts, and
with large children. Naturally those cases in which the
mechanism of labor was abnormal through posterior
rotation of the occiput, face presentation or breech presen-
tation, predisposed to laceration of the cervix. While
primary closure of laceration of the cervix was indicated
in the conditions just described, certain conditions were
necessary for its successful performance. These con-
ditions were outlined. Dr. Davis then described the
technique of the operation, and the after-treatment. The
number of cases under observation was 53. In these,
good union occurred in 45, fair union in 6, no union in 7,
while infection developed in none. In 84.9 per cent, the
operation was successful ; in 1 1.3 per cent, it was moderate-
ly successful, and in 3.8 per cent, the operation failed.
The percentage of infection was nil. He pointed out
the objections which were commonly urged against this
operation, after which he said that in appropriate cases
in his experience immediate closure of the cer\ix had
given no inconvenience to the mother, and had been fol-
lowed by excellent results. The operation was not ad-
vised for those who do not practise obstetrics with good
surgical technique, and who were not competent to operate
on the genital tract.

Cervix Suture on the Fifth Day after Delivery. —
Dr. RoBHRT L. Dickinson of BrookI\-n said that
no complicated or considerable perineal injury should
be repaired at the close of labor, but three to five days
later. This had an important bearing on lacerations of
the cer\'ix, as this was the ideal time to restore such in-
juries. The huge oedema, the bruising, and the uncouth
distortion of the vaginal portion just after delivery ren-
dered identification of the parts that should be brought
together impossible, and attempt to coapt accurately,
guess w^ork. Therefore, whenever possible, the cervix
should be sewed on the fifth day. The frozen sections of
the puerperal weeks showed that then, and not till then.

shrinkage had occurred. Bleeding no longer obscured
the difference between flayed surface and torn structure.
Then only were the svirroundings of the operation, in the
way of illumination, table, time, and a rested personnel
possible. This applied particularly to private practice.
The conditions under which the cer\-ix should be repaired
at the close of labor were: (1) Bleeding from a firmly con-
tracted uterus, notwithstanding ergot, heat, holding,
and tampon. Here there was a spurting artery. (2)
When the cer\'LX injuries were clean cuts, of known loca-
tion, as after Duhrssen incisions. (3) When, in the im-
mediate repair of a moderate perineal injury, a tear of
the cervix is found. The conditions under which the
cervi.x should be repaired several days after labor were:
Exhaustion of patient, or surroimdings and conditions
which precluded careful work. (2) Extensive injuries,
except when these persistently bled or had been cut by
the surgeon. (3) When accompanied by complicated
or considerable injuries to the pelvic floor. The author
drew attention further to the alterations produced by
granulation and contraction in these wounds when left
alone, so that the scarred, swollen, averted, or cystic cer-
vi.x months or j-ears after injury gave uncertain indica-
tions for accurate restoration to the original condition.

. General Considerations of Laceration of the Cervix
Uteri. — Dr. J. M. Baldy of Philadelphia staled that
as a matter of clinical fact, let the cer\ix uteri be torn
deeply and if the parts were preserved from infection,
the greater part of the tear would heal spontaneously,
and the rest of it would remain perfectly healthy, as
much so as would the lobe of the ear which had been torn
through by the weight and drag of our great-grand-
mother's earrings. The lips would remain tuiinfiltratcd,
of normal size and thickness, with no eversions and no
erosion of the lining mucous membrane. In such a
case there would be no untoward symptoms and no bad
effects whatever. There was a tendency amongst ob-
stetricians to repair these lacerations primarily. The
objections to such practice were manifold, and he ad-
mitted a prejudice against it. These objections were
pointed out. Whatever might be ideal surgery under
the exigencies of actual practice, the treatment for
recent lacerations of the cervix remained, and he be-
lieved would remain, rigid local cleanliness, excepting
where there was sufficient hemorrhage to demand a liga-
ture. Where non-infection could be insured, and where
the torn lips were not unnecessarily disturbed, by the
careless use of the nozzle of a syringe, spontaneous healing
of these lacerations might be expected to a greater or
lesser degree, and what tear remained, when nature was
through with her work, would be of a healthy character,
would give no future trouble, and would need no surgical
interference. The symptoms of chronic lacerations of
the cervix uteri were essentially local in their production
and remained so in their manifestations. He had no
sym]:>athv with the views which attributed reflex symp-
toms to these lesions. In uncomplicated cases, in which
there existed simply a laceration of the cer\-ix uteri, with
everted and eroded lips, producing a constant leucorrhoea
and a feeling of weight and uneasiness in the pelvis and
about the rectum, these so-called reflex symptoms did
not exist. There was one belief prevalent which would
warrant, nay demand, a repair of every lacerated cervix —
the belief that lacerations of the cervix produced carci-
noma. In this belief he took no part, and no one had, to
his knowledge, as yet produced a single scientific fact
which would uphold such a theory. In twenty years'
work he had not seen a single case of cancer develop
in a laceration of the cer\-ix which he had refused to
repair.

Intrapelvic Haematoma. — Dr. J. Wiiitridge Williams
of Baltimore reported a case of intrapelvic haematoma
following labor, and made some remarks on the treat-
ment of incomplete rupture of the uterus.

July 1 6, 1904]

MEDICAL RECORD.

II-

President's Address. — Dr. Edward Reynolds of Boston
in his presidential address, said, among other things,
that the society owed its preeminence along its chosen
line less to the words than to the prolonged and daily
labor of the eminent men who had composed it in the
past, and must owe its future to the lifework of the
equally able men who were to fill its membership in the
coming years. He said the use of the printed abstract
pulilished beforehand had of late become increasingly
prominent in many societies, and in the British Medical
Association this use of the abstract had reached its
highest terms. It was seldom wise to adopt wholesale
the regulations of other organizations. It was usually
better to let changes follow a more gradual and natural
ev-olution under the needs of the individual a sembly,
but the methods of the English association were worth
a passing consideration. A Fellow of the British Medical
Association who desired to present a paper at one of its
meetings, must put it in the hands of the secretary com-
plete and in the form in which he desired its publication
a number of weeks before the meeting, and the com-
munication might be of any length he chose. A paid
secretary, a (lualified and experienced medical author,
then abstracted each paper in the form and length which
he considered best fitted for its public delivery. This
official then read the abstracts to the society as they
were called from the program. Such a reading inaugu-
rated each discussion, and the member whose ideas had
been thus succinctly set forth before his associates took
part in the discussion and closed it. The ideas of indi-
vidual members by this method were better and more
intelligently presented to the society than if they had
read their complete papers. In this way the time of
the society was economized, full debate was encouraged,
and the members had the advantage of publishing to the
world papers in which their points were set forth at the
fullest length and without time limitation. Dr. Reynolds
said that such a method was perhaps too far advanced
for our present needs or possibilities, yet it had many
advantages, and it seemed to him worth calling attention
to as one toward which the society might well advance.

Would it not be wise to give this method, or a modifi-
cation of it. a year's trial ? In conclusion he expressed
his thanks for the kindly personal feeling which had
actuated the Fellows when they elected him president,
for which, and for the many personal pleasures which he
had enjoyed in the society, he was, and would always
gladly remain, their willing debtor.

The Preventive Treatment of Pelvic Floor Lacerations.- —
Dr. J. Clifton Edgar of New York read this first paper
in a symposium on injuries to the perineum. The most
important part of the management of the second stage of
labor was the prevention of pelvic floor lacerations,
lacerations of the fourchette in primipar^E, and superficial
tears abotit the vulvar orifice in both primipara and multi-
para often occurred, were often unavoidable, and usually
readily healed with simple asepsis. Deep lacerations were
avoidable in normal, ordinary cases of labor. The factors
which tended directly or indirectly to produce pelvic floor
lacerations were numerotis, but for convenience he ar-
ranged these in three major classes. These were concisely
stated as (i) too rapid expulsion of the foetus, so that
tearing instead of stretching resulted. (2) Relative dis-
proportion in size between the presenting part and the
parturient outlet. (3) A faulty mechanism of labor,
whereby the larger circumference of the head and shoul-
ders than necessary passed through the parturient outlet.

From an extended clinical experience, he covild speak
most enthusiastically of the preliminary digital stretching
of the vulvar outlet in primipara, and especially in elderly
primipara, as a prophylactic measure in perineal pro-
tection. Regarding shoulder delivery, the author firmly
believed that the posterior shoulder was responsible for
many instances of deep pelvic-floor laceration. Further-

more, moderate ruptures caused by the passage of the
head were often increased and rendered serious by
the subsequent passage of the posterior shoulder. He
had been most successful with the following method
of shoulder dehvery, and either the lateral or dorsal
posture of the patient could be used at will. This method
was not new: (i) The delivery of the shoulders was de-
layed, if possible, until nearly complete rotation of the
bisacromial diameter had taken place. (2) The fetal
head was taken in the hand and gently raised or pushed,
so as to bring the anterior shoulder well up behind the
symphysis, thus giving the cervico-acromial diameter of
the foetus at the outlet instead of the bisacromial. (3)
The posterior shoulder was now allowed to pass out spon-
taneously and whenever possible manual extraction should
be avoided, as this increased the risk of perineal rupture.
(4) During the detention of the anterior shoulder behind
the symphysis, the fetal hand of the opposite arm lying
across the fetal chest would usually soon appear in the
vulva. He had found that deUvery might be safely
assisted by slowly flexing this forearm and arm out through
the vulva and thus delivering the posterior shoulder by
slight tracticn on the posterior arm. (5) Should the
foregoing be impracticable and delay in the expulsion of
the posterior shoulder occtir, he had found gentle traction
upon the head, the fingers encircling the neck, to be prefer-
able to traction with a finger in the axilla. (6) Should
there be delay in the delivery of the anterior shoulder,
after expulsion of the posterior, it was best remedied by
making traction directly downward, with the hands placed
on the sides of the head, taking care not to make too great
pressure on the perineum. As a last resort, traction might
be made by a finger in the axilla.

Placing Sutures before the Lacerations Occur. — Dr.
L.\PTHORNE Smith of Montreal spoke of the importance of
closing up even small tears of the perineum, so as not to
leave raw surfaces for septic absorption. It was impor-
tant to close large tears eg as to retain the function of the
pelvic muscles. The best time to put in these stitches was
just before the head pressed on the perineum, while the
patient was anaesthetized, and before the parts had lost
their relative positions. With the left finger in the vagina
and the thumb in the rectum, a large perineum needle on
a handle was passed just under the vagina, threaded with
silkworm gut ; the two or three stitches himg loosely in a
Pean forceps until the placenta had been delivered, when
they were quickly tied, bringing the parts exactly together
as they were before the tear.

Immediate Kepair of Injuries of the Pelvic Floor. — Dr.
Henry C. Coe of New York said that he had selected this
topic in order to emphasize the fact that by careful
attention to puerperal lesions at the time of their occur-
rence the patient could be spared much future trouble.
He assumed that it was the usual practice of modem
accoucheurs to repair injuries to the pelvic floor at once,
but it was one thing to suture visible tears and another to
repair deeper lesions. Even when perfect union of the
lacerations was obtained, the occurrence of prolapsus,
cystocele, and rectocele months afterward proved that
there had been some fault in the technique. The fact of
the separation of the fascia and leva tores ani muscles
must be recognized as well" as the superficial tear,
especially after difficult instrumental deliveries. An
illustrative case from the writer's practice was cited. The
tendency of the accoucheur after a tedious instrumental
case, in which both physician and patient were exhausted,
was to spend as little time as possible in repairing lesions
of the soft parts, trusting to aseptic technique to insure
perfect healing. The writer was firmly of the opinion that
it paid to do the work thoroughly at the time, unless the
patient's condition was such as to render delay advisable.
He had had such good results from immediate operations
that the intermediate did not appeal to him. In con-
clusion, he alluded to the fact that the modem accoucheu

ii8

MEDICAL RECORD.

Qtily 1 6, 1904

must be a surgeon as well as an obstetrician. It was
e.xpected of hini to leave the patient in as good condition
as he found her, otherwise he properly laid himself open
to criticism.

Uniformity in Pelvic and Cranial Measurements. — Dr. A.
F. A. King of Washington, D. C, read a paper on this
subject in which he reached the following conclusions:
"(i) That at present the measurements of the normal
pelvis and fetal head are indefinite and unsettled, and must
continue so to be so long as they are determined by our
present methods of mensuration. (2) The chief purpose
in obtaining the normal dimensions of these structures
being £or teaching and learning the normal mechanism
of labor, it is proposed to adopt an ideal or hypothetical
head and pelvis, upon the dimensions of which all author-
ities may agree. (3) In the adoption of such ideal struc-
tures, it is imnecessary and undesirable to define any
measurement with exact precision — no fraction smaller
than one-fourth of an inch, or than half a centimeter (in
the metric system) being required. (4) Race variation
forms no real obstacle to the proposed plan, and other
apparent difficulties can be overcome. Finally, should
the proposition meet with approval, it is suggested that
this society take the initiative in bringing the matter in
proper form before some forthcoming international medical
congress for general adoption."

Accordingly, a committee was appointed by the presi-
dent to consider the matter of imiformity in pelvic and
cranial measurements, and report at the next annual
meeting.

Non-operative Local Treatment in Gynecology. — Dr.
Willis E. Ford of Utica, N. Y., in reading the first paper
in the symposium on this subject, said that no one would
deny that greater good had come from surgical treatment
of diseases peculiar to women than was ever dreamed of
by the early gynecologists who did not operate. No
comparison of results could be made. He did not think
it was true, however, that the specialty ought to become
purely surgical. Pathology learned by pehdc and ab-
dominal Surgery ought to be clearer and better than was
ever discovered post-mortem. It was fair to assiune
that men who did this work had a better idea of the natural
history, progress, and dangers of these diseases than those
who did not operate; and that, therefore, the early treat-
ment ought to be in the hands of men who were also doing
surgical work. The nervous habit could not be cured
by surgical procedure. What was commonly called
neui asthenia was not a disease, but an established habit,
possible only to those who had from birth an unstable or
weak nervous constitution. Before the mental symp-
toms began was the time to prevent neurasthenics from
becoming permanent invalids. That the nervous habit
could not be cured by surgery had been proven by the fact
that the removal of diseased ovaries, and such like opera-
tions on epileptic women, had not cured the epilepsy or
neurasthenia. The argument, therefore, was that in those
ailments that tended to disturb the emotions, especially
those of the reproductive organs of men or women, the
the serious thing was not the pain experienced, but the
permanent invalidism which was brought about by the
protracted local sensations that in time disturbed the
mental equilibrium and brought about the invalid habit.
These local irritations ought to be treated bv skilled
gynecologists, and not allowed to develop either the men-
tal or physical ailments which were so common a result.
These arguments were enough to make the profession
to revive its interests in non-operative procedures. Re-
cent displacements, especially in young people, and acute
infections were mentioned as demanding non-surgical
care early, if one wished to avoid the more serious ailments,
and especially the most serious of all, the mental disorder
called neurasthenia.

Dr. Walter P. M.^ntom of Detroit. Mich., said that
the ignorance of proper methods, together with the fas-

cinations of operative measures, had brought the local
treatment of pelvic disease into disrepute. Three of the
factors, which among others at the present time were
largely responsible for the neglect of medical gynecologj".
were: (i) The average physician's lack of knowledge
in the accurate diagnosis and local treatment of pelvic
disease. (2) The allurements and fascinations of sur-
gery, and (3) competition in the field of practice. While
it was true that no amount of instruction could impart a
tactus eriidiins, stiU anyone could acquire a knowledge
of the primary principles imderlying the correct inter-
pretation of gynecic ailments, if opportunity was offered
for the practical examination of patients imder competent
direction. In ignoring the benefits to be derived from
medicine, he was convinced that surgery had gone too
far and that it had overshot the mark, but that the present
tendency to operative measures in all conditions affecting
the pelvic organs could not be ascribed so much to the
good which surgerj-, rightly directed, was capable of
accomplishing as to other elements which had entered
into the case was also e\-ident. In the best of hands the
results from local treatment in pelvic diseases were fre-
quently slow in manifesting themselves, and discourage-
ments were often met with, but in suitable cases persistent
eflfort would ultimately attain the desired end. The
objects of local treatment were the relief of pain and
irritation, often of a reflex nature; the allaying of conges-
tion and inflammation : the absorption of the products of
inflammation, and the reposition of displaced organs. In
the regulation of the uterine functions, in congestions
and mild inflammations of that organ and surrounding
parts, and in displacements of the uterus, w^th and without
adhesions, the application of proper local treatment was
of signal value; while in prolapse of the tubes and ovaries,
even in the presence of extensive adhesions, but without
. ascertainable morbid changes in the organs themselves,
vaginal tamponade offered the simplest and most efficient
means of reposition and cure.

Treatment Preparatory to Operation. — Dr. Hexry C.Coe
of Xew York introduced his remarks with the statement
that while his early training had led him to believe that
such treatment was practically indispensable in cases of
so-called "cellulitis," subsequent experience had con-
vinced him that this notion was not in accordance with
pathology or common sense. He had expressed skepti-
cism on this subject as long ago as 1S86, when he read a
paper on the "Exaggerated Importance of Minor Pelvic
Inflammation," and subsequent experience had only
ser\'ed to confirm his opinion that old pelvic exudates and
adhesions were not per se a contraindication to operations
on the uterus. Modem aseptic technique was a suf-
ficient safeguard against danger from this source. The
reader contrasted the old practice of keeping a patient in
a hospital for several months, with the preparatory treat-
ment between each minor operation, w-ith the present
plan of performing a combined operation at one seance
and sending the patient out in three or four weeks.
He questioned the actual value of the hot vaginal
douche, local applications to the vaginal fornix, etc ,
previous to trachelorrhaphy. At the same time, he
admitted the remarkable results often obsen-ed as
regards the absorption of extensive pelvic exudates.
.Acute and subacute inflammations in and around the
adnexa formed the real contraindication to opera-
tion, and doi^btless surgeons were not always as
careful as those of the former more conservative genera-
tion in selecting their cases. Competition and the rush
of modem life were responsible for some ill-advised opera-
tions, minor as well as major. In regard to major opera-
tions, the author thought that (excluding pus cases)
general preparatory' treatment of the patient was rather
more important than local. He believed, however, that
the admirable results obtained by the pioneers in the
treatment of vesicovaginal fistula' were due to careful

July i6, 1904]

MEDICAL RECORD.

119

preparatory treatnaent, such as the division of cicatrices,
stretching of the vagina, etc. Fortunately we were sel-
dom called upon to handle such complicated cases as those
described by Sims, Emmet, and Bozeman. With all our
improvements in technique, we had not yet outgrown all
the wisdom of our old teachers.

Postoperative Local Treatment. — Dr. J. Riddle Goffe
of New York said the experience of all observers was that
local treatment relieved congestion, pain and discomfort;
inaugurated, hastened, and accomplished the absorption
of oedema, plastic exudate, adhesions, and pseudo-hyper-
trophy. . If it wotdd relieve these conditions, how much
more certainly would it prevent them.? It had been
found serviceable in preventing the deposit of plastic
exudate and the reformation of adhesions in cases in
which these were present at the time of operation. It was
especially valuable in cases subjected to vaginal section
for the relief of sterility. The author reported several in-
structive cases to substantiate the pointsmadeinhis paper.
The Implantation of the Human Ovum in the Uterus. —
Dr. Charles Sedgwick Minot of Boston discussed this
subject by request. He stated that the human ovum
produced upon its exterior during its earliest stages of
development a thick layer of cells, the trophoblast. The
function of the trophoblast was to corrode away a portion
of the mucous membrane of the uterus, making a cavity
in which the ovum lodged itself. The trophoblast there-
upon underwent a hypertrophic degeneration, such as to
produce a series of irregular spaces, which persisted and
became the intervillous spaces of the placenta. Papillary
outgrowths of the chorionic mesodenn meanwhile pene-
trated the trophoblast, initiating the formation of the
chorionic viUi. The trophoblastic cells over each meso-
dermic outgrowth persisted in two layers, the inner cellu-
lar, and the outer syncytial. These two layers repre-
sented the first stage of the villus ectoderm. Similar
observations had been made upon primates, and were com-
pared with those upon the human subject. He compared
briefly the method of implantation in man with that
in other animals, to show that the trophoblast was of
general occurrence, and that by destroying uterine tissues
it inaugurated the formation of the true chorionic placenta.
Bathing During the Menstrual Period. — Dr. J. Clifton
Edgar of Xew York said that in the consideration of this
subject several questions suggested themselves, namely,
first, the advisability of bathing of any description during
the menstrual period, and if at all, to what extent. Second,
the use of the bath in dysmenorrhoea. Third, the use of
Nauheim or other chemical baths or hydriatic procedures.
Fourth, the risk of infection of the endometrium in in-
tramenstrual tub-bathing. Fifth, the influence of modem
athletics on women, lessening the risk, if any, of intra-
menstrual bathing. These questions were submitted to
the members of the society, from whom he had received
one hundred and twenty- two acknowledgments. From
the replies received, and the literature on the subject,
he drew the following conclusions: " (i) All forms of
bathing during the menstrual period are largely a matter
of habit, and usually can be acquired by cautious and
gentle progression, but not for every woman does this
hold good, and surf bathing, where the body surface
remains chilled for some time, should always be excepted.
(2) A daily tepid sponge bath (85° to 92° F.) during the
menstrual period is not only a harmless proceeding,
but is demanded by the rules of hygiene. (3) In the
majority of, if not all, women, tepid (85° to q2° F.) sponge-
bathing after the establishment of the menstrual flow,
namely, second or third day, is a perfectly safe practice.
(4) Furthermore, in most women the habit of using the
tepid shower or tub bath after the first day or two of the
flow can with safety be acquired."

The Streptococcus in Gynecological Surgery. — Dr.
Hunter Robb of Cleveland. Ohio, stated that in order
to arrive at some definite conclusions with reference to
the streptococcus pyogenes as a cause of death in his

work, he had made an analysis of all his cases in which
this organism had been found during the past six years.
It was shown from observations that quite a large niunber
of liis patients died, and several were unimproved. It
was also noticed that in the great majority of cases in
which this organism was met with, there was a previous
history of infection following labor, or an induced criminal
abortion. In the past six years he had had 137 cases
of abortion (.including a few cases of labor), in which
it was necessary to carry out some form of treatment.
Of this number, 104, or 75.9 per cent., recovered; 17, or 12.4
per cent., were improved ; i , or .8 per cent., was unimproved .
and 15, or 10.9 percent., died. In 16 of the 137 cases the
streptococcus was found. The total number of all his
cases in which the streptoccocus was found was 40, con-
sequently those in which this organism was found following
an abortion or labor formed 40 per cent, of the total
number of streptococcus cases from every source. Of
these, 16 patients (streptococcus cases), following abortion
or labor, 4, or 25 percent., recovered; 3, or 18.75 percent.,
were improved; 9, or 56.25 per cent., died. In the whole,
40 cases from every source, in which the streptococcus
was foimd, the results were as follows: Recovered, 20,
or 50 per cent.; improved, 6, or 15 per cent.; deaths,
14, or 35 per cent. The streptococcus was found in the
following combinations, given in order of frequency:
(i) Streptococcus alone; (2) streptococcus and staphy-
lococcus pyogenes aureus; (3) streptococcus, staphy-
lococcus aureus, and bacillus coli communis. In all
these cases, except three, in which they were obtained
from the vagina, the organisms were obtained from the
titerus, the adnexa, the cul-de-sac, or from several of
these situations. In other words, they were proved
to be present in places which were admittedly not their
normal habitat. In the past five years he had had 724
abdominal sections, with a total number of 32 deaths,
or 4.43 per cent. In 7, or 21.9 per cent., of them the
streptococcus pyogenes was demonstrated. In all there
were 19 cases of abdominal operations in which the strep-
tococcus was found. Of this number, 12 recovered, or
63.2 per cent.; and 7 died, a mortalit)' of 36. S per cent.

Indications for Operation for Fibroid Tumors of the
Uterus. — Dr. Charles P. Noble of Philadelphia pre-
sented a table of the degenerations and complications in
a series of 1,188 cases of fibroid tiimors operated upon
by Martin, Noble, Cullingworth, Frederick, Scharlieb, and
in a series reported by Htmnerand MacDonald. Especial
attention was called to the relative frequency of adeno-
carcinoma of the uterus as compared with epithelioma
of the cervix. The deduction drawn from this fact was
that fibroid tumors were a direct predisposing cause of
cancer of the cervix. A careful consideration of the
facts presented in the table, said the author, should con-
vince anyone with an open mind that the classical teach-
ings concerning fibroid tumors were erroneous. This
teaching was that fibroid tumors of the uterus were
benign growths, which usually produced but few symp-
toms, and which after the menopause underwent re-
trogressive changes, becoming smaller or disappearing;
that the chief danger of fibroid tumors consisted in the
fact that at times they caused hemorrhage from the
uterus, and that rarely they caused trouble, because of
their size or because of pressure on adjacent viscera. An
analysis of the 1,188 cases showed that because of the
degenerations in the tumors, about 16 per cent, of the
women would have died without operation; about 18
per cent, would have died from the complications present.
In addition, it was well-known that a certain percentage
would have died from intercurrent diseases brought
about by the chronic anaemia present in many of these
cases, and by injurious pressure from the tumors upon
the alimentary canal and urinary organs. In brief, at
least one-third of the women having fibroid tumors, as
shown by the author's table, would have died had they
not been submitted to operation.

I20

MEDICAL RFXORD.

[July i6, 1904

The Treatment of Gonorrhoea. — Dr. Henry T. Bypord
of Chicago said there was dissatisfaction with prev-
alent methods of treating this disease. The desidera-
tum was a local remedy that would rapidly destroy or
remove the germs without injuring the protective epithe-
lium, and a method of application that could be used by
the patient which would not carry the germs to a deeper
portion of the genitourinary tract. He advocated
prolonged irrigations with hot water as a basis, and
spoke of frequent injections of hot water as a substitute
for prolonged irrigations. He detailed his experience
with urethritis in the male, and referred to hydrogen
dioxide and unirritating germicidal solutions as sub-
stitutes for plain water injections, and gave their ap-
plication to gonorrhoea in the female. The advantages of
this treatment, when used early, were summarized by him
as follows: "(i) It prevents the spread of the disease to
adjacent parts. (2) It does not injure the epithelial cover-
ing, and tends to limit the infection to the superficial
areas. (3) It removes more germs and pus cells than either
astringents or disinfectants can destroy. It acts in the
same way as constant irrigation, both in aborting and
arresting the progress of the infection. (4) It can be
used more frequently than astringents or strong ger-
micides, so that the parts can practically be kept free
from pus and germs all of the time, while the method
of using germicides or astringents three or four times
daily allows the germs and pus to accumulate and spread
between injections. (5) In the male, and possibly in
the female, peroxide injections may be substituted when
the time and facilities for the hot water treatment cannot
be had. When the discharge has become scanty and the
injections cannot readily be used so frequently, a. non-
irritating solution of a silver salt can follow each hot
water or peroxide treatment. (6) It may be used in
connection with other injections for the dissolving of
germs and culture material not eliminated by the douches.
(7) It does no harm. It can be combined with the
internal or local medication when it becomes impossible
to carry it out with the necessary time-consuming
detail It exemplifies the superiority of asepsis to anti-
sepsis."

Dr. Philander A. Harris of Paterson, N. J., exhibited
and described a new uterine obstetrical dilator.

OflScers. — The following officers were elected: President,
Dr. E. C. Dudley, Chicago, 111.; Vice-Presidents, Drs.
Henry D. Fry, Washington, D. C, and Henry C. Coe,
New York; Secretary, Dr. J. Riddle GofFe, New York;
Treasurer, Dr. J. M. Baldy, Philadelphia.

Niagara Falls, N. Y., was selected as the place for
holding the next annual meeting, in May, 1905.

Treatment of Tabes. — O. Zicmssen discusses his method
of handling this disease, which he bases on the assumption
that the cord lesions are due to a disturbance in the
capillary system, and that when the latter is righted the
diseased tissues are regenerated. It is necessary to dis-
tingxiish between the less prominent elementary disease
and the secondar\' effects, which are a source of greater
annoyance. Different remedies may be directed against
one of these factors without in any way influencing the
other. Ziemssen first places the patient on a thorough
mercurial treatment, and unless this is carried out dili-
gently the result is always failure. The method to he pre-
ferred is by inunctions. In addition to this the amount
of fluids is restricted, as in other circulatory diseases,
and special measures are directed against the secondary
manifestations, such as the ataxia, incontinence, neuralgia,
etc. Even where the tabes has closely followed upon a
traxima, the author has used the inunctions and later found
that the patients had had syphilis. It is essential in
every instance to begin treatment as early as possible, for
as a rule the disease has existed for some time before the
patient prc-^nts himself for examination. — Wiener klinisch-
Iherapeuiisclie Wocheiischrift.

Contagious Diseases — Weekly Statement. — Report of
cases and deaths from contagious diseases reported to
the Sanitary Bureau, Health Department, New York
City, for the week ending July g, 1904:

Ueasles

Diphtheria and croup

Scarlet fever ,

Smallpox

Varicella

Tuberculosis

fypboid fever

Cerebrospinal meningitis

Cases.

Deaths.

261

297

»3

359

136

An Unusual Form of Influenza. — J Latkowski reports
a localized epidemic disease characterized by a sudden
invasion, chills and fever, swelling of the eyelids, muscular
pains, and general prostration. Examination of the
secretion from the conjunctiva showed the presence of
the influenza bacillus. This swelling of the lids is an
unusual phenomenon, and the author believes that the
connective tissue forms the portal of entree for the germs,
from which they are distributee! through the body. —
Wiener klinisch-iherapeutische Wochenschrift.

Health Report. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the Surgeon-General, U. S. Marine Hospital Service,
during the week ended July 9, 1904:

SMALLPOX UNITED STATES.

Delaware, Wilmington June

District of Columbia, Washington .June

Florida, at large June

Georgia, Macon June

Illinois, Belleville June

Chicai^o June

Danville June

Kentucky. Co\*ington June

Louisiana, New Orleans June

Maine, Madawaska Region June

Michigan, Detroit June

At 88 localities June

Missouri, St. L#ouis June

Nebraska, Omaha June

New Hampshire, Manchester June

New York, New York June

Ohio, Dayton June

Pennsylvania, Altoona June

Philadelphia June

Steelton June

Tennessee, Memphis June

Nashville June

2s-July 2.

iS-25

18-25

3S-July 2

1-30

2 5 -July 2
2 5 -July a
2S-July 2
2«;-Julv 2

18-25 -■

14-21

i8-2S

25-July 2
25-July 2
25-July 2
2 5- Jul V 2
1 8- July 2
25-july 2
July 2
July 2
-July 3
July 2

CASES. DEATHS.

Present

25-
25

SMALLPOX FOREIGN.

.\ustria, Prague June ii-i8

France, Paris June 1 1-18

Great Britain, Bradford June 4-18

Bristol June 11-25

Cardiff June 4-1 1

Edinburgh. ' June 4-1 1

Glasgow June 17-34

Liverpool June ii-iS

London Tunc 11-18

Manchester June 4-18

New-Castle-on-Tyne June 1 1-18

South Shields June 11-18

India, Bombay May 31-lune 7 .

Calcutta May 2S-June 4 .

Karachi May 29-June 5 .

Panama. Panama June 12-19

Russia, Moscow June 4-1 1

St. Petersburg June 4-18

Warsaw May 14-21

Warsaw^ May 28-June 4 •

Spain, Barcelona May 20-June ao.

Turkey, Alexandretta June 4-11

Beirut May 28-June 4 .

Constantinople June 12-19

IS
6

Present

YELLOW PEVBR.

Ecuador. Guayaquil May 3 5- June 8 is

Mexico, Merida June 12-18 7 >

Vera Cruz June 18-25 * '

Panama, Panama June 1 2-19 1

PLAGl'E.

Africa, Johannesburg Apr. i i-May t . . . . 2 3

Australia, Brisbane May 3-2 1 7 2

Sydnev May 14-21 i

E^ypt May 21-28 ao 10

includint: Alexandria, i case, i death; Port Said, i case. 1 death.

India, Bombay May 3t-June 7 78

Calcutta May 28-June 4 7°

Peru. Payta May 29-June 4 ... 1 1 7

CHOLERA.

India. Calcutta May 28-June 4 24

Madras May 28-June 3 a

Turkey, Bahrein Ulands; Miy 10 Epidemic.

Medical Record

A Weekly Journal of Medicine and Surgery

Vol. 66, No. 4.
Whole No. 1759.

New York, July 23, 1904.

$5.00 Per Annum.
Single Q>pies, 10c.

(Original ArtirlpH.

NOTES ON SOME UNCOMMON FORMS OF
NERVOUS DISEASES.*

Bt L. pierce CLARK, M.D.,

NEW YORK.

VISITING NEUROLOGIST TO THE RANDALL'S ISLAND HOSPITAL AND
schools; consulting NEUROLOGIST TO THE MANH.\TTAN STATE
HOSPITAL. NEW YORK.

I DESIRE to place on record the following short
abstracts of some uncommon forms of nervous dis-
ease in patients that have presented themselves at
the Vanderbilt Clinic during the past two years.
I am much indebted to Dr. Starr for his kind per-
mission to publish the cases;

Multiple Neuritis with Intact Reflexes. — Case I —
J. S.. five vears old, whose case is incorporated
in this report by kindness of Dr. Hart, is an imbecile
and possibly epileptic. He was born at term with
instruments after a prolonged dry labor of eighteen
hours. He was much asphyxiated, but no con-
viilsions were reported. There were scrofulous
suppurating glands of the neck at six months.
He only began to talk at three years of age. July,
1902, he suffered from what the family supposed
was gastritis, but which was probably lead colic ;
he recovered entirely, and was well for two weeks,
until September 15, 1902, when it was noticed one
morning that he was lame in both feet and there
was bilateral foot-drop. Two months after his
hands became affected in the same manner, show-
ing the characteristic wrist-drop of lead palsy. He
handled lead during the two weeks after recovery
from the illness in the summer and again in Sep-
tember. The relatives believe his taking strong
medicine during the summer had something to do
with it, but this seems improbable from the history
of treatment. At present he is in the recovery
stage of multiple neuritis, apparently of lead
origin. All reflexes are exaggerated; no sensory
changes. Great diminution of faradic and galvanic
current, but no qualitative change.

In multiple neuritis the reflex action in the
muscles is almost invariably lost (Gowers , but in
rare cases, such as those reported by Dejerine, it
may persist. Its retention, however, is exceptional,
and probabl)' depends on the escape of at least some
of the fibers on which the action depends. The
retention of the knee-jerk throughout the entire
course of the disease cannot be explained on the
basis that they are sometimes excessive in the early
stages of the disease (in consequence of an irritable
state of the nerves on which they depend) similar
to that which gives rise to hyperassthesia. On the
the other hand, usually in the slightest grades of
neuritis the reflexes are lost, however muscle ten-
derness is almost invariably present, indicating an
involvement of the afferent sensory nerves.

Myoclonus. — Case II — B. S., eleven years old,
Jewish. Two years ago, without rheumatism, heart
disease, or fright or other known causes, a lightning-
like clonic spasm developed in the left biceps,

*Read before the .Academy of Medicine, Section on
General Medicine, Ma v 17, 1904.

triceps, pectoralis major, latissimus dorsi and
sternomastoid, and in a few weeks the same muscle
of the right arm also became involved. The spasm
was then as now nearly bilateral, lightning-like, and
clonic in character, occurring twenty to forty times
a minute. There were good and bad days, but
there was never more than a few minutes of entire
freedom from the spasm. In a few months the
muscles of the pelvic girdle became involved, par-
ticularly the glutei, quadriceps, the adductors, and
the sartoriis. He had no difficulty in swallowing;
there was, however, a diaphragmatic grunt. He
cannot inhibit the morbid movements now as long
as formerly. Of late the supinators of the forearms
and peroneal group in the legs have been occasion-
ally involved. No spasm in fingers or toes have
ever been observed, although of late infrequent
facial spasms have occurred. The muscles in-
volved first in the disease are now involved most.
Musculature is good ; no atrophy ; no sensory changes ;
all reflexes are normal. There is marked disturb-
ance in writing. He inhibits the spasms while
writing single words, and then in the frequent
pauses the "jerks" are intense. The worst sample
given here was on one of the patient's "bad days,"
when the uninhibited spasms were so sudden and
brisk as to make "rockets" before the hand could
be voluntarily withdrawn from the paper in the act
of writing.

The illustrations on the following page are copies
of the handwriting in this case of myoclonus: (For
similar specimens see the report of the author's
cases inthe Archives of Neurology and Psychopathology,
Vol. 2, Nos. 3-4, 1899.)

Cases of myoclonus, although not rare, are still
uncommon. In diagnosticating the affection we
permit a wider latitude in the disease complex than
formerly. Although the essentials of the affection
are usually held to embrace the symptom of bilateral
clonic lightning-like muscular spasm involving
proximal muscles most or exclusively, cases are un-
doubtedhr reported in which one or more of these so-
called essentials are very much modified or absent.
It is intere.sting to note in France, where the tics
have been most thoroughly studied, that the names
of "multiple tics" and "electric chorea" (Henoch-
Bergeron's disease) still do service for many ob-
viously well-marked cases of myoclonus. Even
in this country myokymic (Schultze) as well as
multiple tics and electric chorea are frequent designa-
tions for myoclonus. In Russia also Koschewniskow's
epilepsy can hardly be other than myoclonus-
epilepsy. Bechterew also reports from time to time
altogether too many cases of choreic epilepsy. The
latter is an extremely rare association in the experi-
ence of most neurologists. We believe, as
Oppenheim holds, that these peculiar tics and
choreas should be arranged under the head of
myoclonus. It will then be possible for us prop-
erly to classify the different types of the affection.
An ambitious attempt in this direction has alreadv
been undertaken by Dana in the Journal of Nervous
and Menial Diseases, June, 1903.

122 MEDICAL RECORD. [July 23, 1904

Paradoxical Pseudohypertr